4. Immunisation of special groups

This chapter discusses the special immunisation requirements of individuals at risk of vaccine-preventable diseases due to certain conditions or underlying disease, or through their occupation or other risk factors. The topics covered are:

• pregnancy and lactation (section 4.1)
• infants with special immunisation considerations from birth (section 4.2)
• immunocompromised individuals (section 4.3)
• chronic kidney disease (section 4.4)
• chronic liver disease (section 4.5)
• other special groups (section 4.6)
• immigrants and refugees (section 4.7)
• occupation-related vaccinations (section 4.8)
• travel (section 4.9).

Note: Vaccinators are advised to check the Pharmaceutical Schedule and any online updates (available on the PHARMAC website) for changes to funding decisions for special groups.

4.1. Pregnancy and lactation

4.1.1. Women planning pregnancy

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, 19.5.3 and 22.5.4).

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 19.6.1).

Varicella vaccine

Two doses of VV are recommended but not funded for adults who are susceptible to varicella (see section 22.5). VV should not be given to those who are pregnant, and pregnancy should be avoided for four weeks after vaccination (see section 22.5.4).

4.1.2. During pregnancy

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 ‎19.8.3) and varicella (section ‎22.8.6), 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, 5.5.5 and 5.5.10) 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 or rCV.

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]

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 ‎15.5).[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 15.5 for information about maternal pertussis vaccine effectiveness and safety.

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.

4.1.3. Breastfeeding and post-partum

Measles, mumps and rubella vaccine

Up to two doses of MMR are recommended and funded after delivery for eligible women who do not have documented evidence of immunity to measles, mumps and rubella. Breastfeeding is not a contraindication to MMR (see section 12.8.3).

Pertussis vaccine (Tdap)

A single dose of Tdap is 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 mothers had not received Tdap at least 14 days prior to birth.

A single dose of Tdap is also recommended but not funded for all new mothers who did not receive a Tdap vaccination during pregnancy.

Varicella vaccine

VV is recommended but not funded for all susceptible adults. Pregnant women who are non-immune can be offered VV after delivery.

If the mother is susceptible to varicella, VV for the mother is recommended and funded after delivery if the baby or other household members are immunocompromised (see section 22.5).

4.2. Infants with special immunisation considerations from birth

Further details are given in section 4.3 for infants born with primary immunodeficiency, including Down syndrome (section 4.3.3), secondary immunodeficiency (section 4.3.4), functional asplenia (section 4.3.12) and HIV (section 4.3.13).

4.2.1. Infants born to mothers with positive or unknown hepatitis B (HBsAg) status

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.

4.2.2. Preterm and/or low birthweight infants

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 4.3.6.

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 16.5.2), 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 (see Table 11.3).

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 15.5). 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]

4.2.3. Infants with congenital heart disease

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 – caution

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.

See Table A6.1 in Appendix 6 for suggested intervals between administration of blood products and MMR or VV.

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 4.3.3). 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 16.5.2).

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 10.2).

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 contacts of infants with CHD are up to date with Schedule vaccinations, to reduce the risk of pertussis transmission to the infant (see section 15.5). 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]

4.2.4. Infants with immunocompromise, including primary immunodeficiencies from birth

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 4.3.12).

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 4.3.6).

4.3. Immunocompromised individuals

This section discusses immunisation recommendations for certain groups with immunocompromise.

• Vaccination of close contacts of immunocompromised individuals (section 4.3.1)
• Immune checkpoint inhibitors (immunostimulant) therapy (section 4.3.2)
• Primary immunodeficiency (section 4.3.3)
• Secondary (acquired) immunodeficiency (section 4.3.4)
• Individuals receiving corticosteroids (section 4.3.5)
• Individuals receiving non-corticosteroid immunomodulatory agents (section 4.3.6)
• Vaccination prior to planned immunosuppression (section 4.3.7)
• (Re)vaccination following immunosuppression (section 4.3.8)
• Oncology (section 4.3.9)
• Haematopoietic stem cell transplantation (section 4.3.10)
• Solid organ transplantation (section 4.3.11)
• Functional asplenia, hyposplenia and pre-/post-splenectomy (section 4.3.12)
• HIV infection (section 4.3.13)

The nature and degree of immunocompromise determines an individual’s immune response and which vaccines are recommended and can be safely administered. Individuals who are immunodeficient or immunosuppressed due to a disease and/or treatment may have an increased risk from infectious diseases. These individuals should be vaccinated as a matter of priority, however, it should be recognised that they have a suboptimal response.

Children aged under 18 years, and adults aged 18 years or older who are eligible to receive publicly funded health and disability services in New Zealand, are eligible to receive the usual Schedule vaccines and additional funded vaccines when they meet the eligibility criteria for special groups.

Vaccinators are advised to regularly check the Pharmaceutical Schedule and any online updates (available on the PHARMAC website) for changes to funding decisions for special groups.

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.

4.3.1. Vaccination of close contacts of immunocompromised individuals

All Schedule vaccines can be given to close contacts of immunocompromised individuals. It is important to ensure that close contacts are immune for the added protection of the immunocompromised individual.

Rotavirus vaccine

Rotavirus vaccine can be given to infants who are in close contact with an immunocompromised individual. The evidence shows that transmission of the rotavirus vaccine virus to contacts is low, and no cases were symptomatic.[15, 16, 17]

Measles, mumps and rubella vaccine

MMR can be given to children and eligible adults who are in close contact with an immunocompromised individual. MMR vaccine viruses are considered non-transmissible; there is no evidence of the current MMR vaccine viruses being transmitted from vaccine recipient to a close contact.[23, 24] See section 12.5 for information about eligibility and the recommended MMR vaccination schedule.

Varicella vaccine and zoster vaccine

Age-appropriate varicella (VV) or zoster (ZV) vaccine can be given to close contacts of an immunocompromised individual. Transfer of vaccine virus to an immunocompromised person is rare and only possible if the vaccinated person develops a varicella- or zoster-like rash. In this situation, the rash should be covered and close contact with the person who is immunocompromised avoided for the duration of the rash.[25] (See sections 22.5 and 23.5 for eligibility.)

Influenza vaccine

Annual influenza vaccination is recommended for all children aged 6 months or older and adults, particularly those who are close contacts of an immunocompromised individual. See chapter 11 for funded vaccine eligibility.

COVID-19 vaccine

For greater protection of high-risk individuals, it is recommended for close contacts of an immunocompromised individual to be up to date (see Table ‎5.2) with COVID-19 immunisation with age-appropriate mRNA-CV from age 5 years; or rCV from age 12 years (for primary course only for ages 12–17 years) or from age 18 years for all other doses.

BCG vaccine

If indicated by the usual BCG eligibility criteria (see section ‎21.5.2), it is safe to give BCG vaccine to infants of immunocompromised household contacts.

4.3.2. 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, mRNA-CV and rCV, without consulting their specialist prior to vaccination. The administration of live vaccines (MMR and VV) is contraindicated.

4.3.3. Primary immunodeficiency

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.[26]

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,[27, 28] and should be considered as primary immune deficiency.

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 21.6.2), 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.[29] Many of these individuals will be on immunoglobulin replacement therapy, which provides passive protection against most vaccine-preventable infections.

COVID-19 vaccine

Children aged 6 months to 4 years with primary immunodeficiency, including children with Down syndrome (trisomy 21), are recommended to receive three doses of mRNA-CV (3 µg) (maroon cap). First and second doses are given at least 21 days apart and dose three is given at least eight weeks after the second dose. 

Certain individuals from 5 years of age with a primary immunodeficiency are eligible for a third primary dose of mRNA-CV (10 µg or 30 µg, as age appropriate) to be given at least 8 weeks after the second dose (see section 5.5.8 for details). A prescription is required for this use.

Regardless of any previous booster doses received after completion of the primary course, an additional dose of bivalent mRNA-CV (15/15µg) is recommended to be given four to six months after previous dose for all individuals aged 12 years and over with primary immunodeficiency, particularly for those eligible for a third primary dose. A dose given  to anyone aged 12–15 years is considered an off-label use and will require prescription from an authorised provider (under regulation s25 of the Medicines Act 1981) (see section ‎5.5.10)

If a significant adverse reaction to mRNA-CV has occurred that contraindicates further mRNA-CV doses, then rCV may be given from age 18 years or age 12–17 years (off-label and requires a prescription), if not contraindicated: in this situation it is recommended to seek advice from IMAC.

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

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 16.5.2).

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 16.5.2 and 16.5.3) 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 16.5.2).

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 16.5.2).

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 16.5.2).

Meningococcal conjugate vaccines

The current funded meningococcal conjugate vaccines are group C and group ACWY meningococcal conjugate vaccines: MenC (NeisVac-C) and MenACWY (MenQuadfi or Menactra).

There is a possibility of blunting of some PCV serotype antibody responses when MenACWY-D (Menactra) is given concurrently with PCV13 because both vaccines contain diphtheria-derived proteins as conjugate. The clinical significance of this blunting, observed in a clinical trial with PCV7,[30] is unknown and the affected serotypes (4, 6B, 18C) are currently rare in New Zealand. The benefits of achieving broad meningococcal protection as early as possible in immunocompromised infants outweigh the theoretical risk of modest reduction of some pneumococcal antibody levels, such that, MenACWY-D is recommended at age 9 months (see Table 4.5 and Table 4.6) rather than waiting until after completion of the PCV13 series. Note: two doses given at least three months apart are recommended as a primary series; ideally, each dose should be given at least four weeks before or after PCV13 to reduce this risk of interference, but PCV13 and MenACWY-D can be given together or at any interval for pragmatic reasons or if an accelerated schedule is required. No blunting or interference with other vaccines is expected with tetanus toxoid conjugated MenACWY vaccines, ie, MenQuadfi offered at any time from age 12 months, or Nimenrix given from age 6 weeks (unfunded).

Note: A second primary dose, of MenQuadfi for those aged 12 months and over and of Menactra for those aged 2 years and over, is off-label and requires a prescription from an authorised prescriber under section 25 of the Medicines Act.

Infants aged under 9 months

Infants aged under 9 months who have an inherited complement deficiency are recommended and funded to receive two doses of MenC given a minimum of eight weeks apart. For broader meningococcal group coverage in infants aged 6 weeks to 9 months, MenACWY-T (Nimenrix) is also available but not funded (see section 13.5).

Infants and children aged 9–23 months

Infants and children aged 9–23 months who are diagnosed with an inherited complement deficiency are recommended and funded to receive two doses of MenACWY. Menactra is given at least three months apart or from age 12 months, two doses of MenQuadfi can be given at 8–12 weeks apart (a prescription is required for a MenQuadfi second primary dose, see note above). For children aged 12 months or older can have either MenACWY vaccine for their second and subsequent doses. A booster dose is recommended after three years then five‑yearly.

Menactra is recommended to be given at least four weeks after PCV13.  MenQuadfi can be given at any time with, before or after PCV13.

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 as part of the NIP 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 and children 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 after 12 months of age given at least six months after the second dose. 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.

Infants from age 12 to 23 months

Infants 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) 

Vaccination advice, by primary immunodeficiency

Below is a summary of the vaccination recommendations for individuals with a primary immunodeficiency.[31] (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.[29] 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.
• 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.

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.

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.[32, 33] 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,[34, 35, 36] and some live vaccines such as measles, mumps and yellow fever.[37]

4.3.4. Secondary (acquired) immunodeficiency

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.[31]

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 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.[38] With specialist input MMR may also be considered in clinically well patients at least 1 year after solid organ transplantation on low level immunosuppression.[39]

See sections 12.5, 22.5 and 23.5 for information about the recommended MMR and VV vaccination schedules and eligibility criteria.

Live zoster vaccine has been discontinued. Individuals from age 18 years with secondary (acquired) immunodeficiency are recommended two doses (unfunded) of recombinant zoster vaccine (rZV, Shingrix). See section 23.5.1.

COVID-19 vaccine

Children aged 6 months to 4 years with a secondary (acquired) immunodeficiency are recommended to receive three doses of mRNA-CV (3 µg) (maroon cap). First and second doses are given at least 21 days apart and dose three is given at least eight weeks after the second dose. 

Certain individuals from 5 years of age with a secondary (acquired) immunodeficiency are eligible to receive a third primary dose of mRNA-CV (10 µg or 30 µg, as age appropriate) to be given at least 8 weeks after the second dose (see section 5.5.8 for details). A prescription is required for this use.

Regardless of any previous booster doses received after completion of the primary course, an additional dose of bivalent mRNA-CV (15/15 µg)is recommended to be given at least four to six months after previous dose for individuals aged 12 years and over with a secondary (acquired) immunodeficiency, and in particular those eligible for a third primary dose. A dose given to anyone aged 12-15 years is considered an off-label use and will require prescription from an authorised provider (under regulation s25 of the Medicines Act 1981) (see section ‎5.5.10).  

If a significant adverse reaction to mRNA-CV has occurred that contraindicates further mRNA-CV doses, then rCV may be given as primary or booster dose from age 18 years or age 12–17 years (off-label, requires a prescription), if not contraindicated: in this situation it is recommended to seek advice from IMAC.

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.

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 10 years who are revaccinated using DTaP-IPV-HepB/Hib will receive three doses of Hib-PRP-containing vaccine.

For children aged 10 years or older and 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.

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 16.5.2).

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 16.5.2 and 16.5.3) once the eligible condition has been identified followed by age-appropriate 23PPV vaccinations.

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 16.5.2).

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 15.5.2).

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 conjugate vaccines

The current funded meningococcal vaccines are group C and group ACWY meningococcal conjugate vaccines: MenC (NeisVac-C) and MenACWY (MenQuadfi or Menactra).

See Meningococcal conjugate vaccines in section 4.3.3 for an explanation of the timing of MenACWY-D (Menactra) and PCV13.

Note: A second primary dose, of MenQuadfi for those aged 12 months and over and of Menactra for those aged 2 years and over, is off-label and requires a prescription from an authorised prescriber under section 25 of the Medicines Act.

Infants aged under 9 months

Infants aged under 9 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 MenC a minimum of eight weeks apart.

For broader meningococcal group coverage in infants aged 6 weeks to 9 months, MenACWY-T (Nimenrix) is also recommended but not funded (see section ‎13.5) to replace the MenC doses.

Infants and children aged 9–23 months

Infants and 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. Menactra is given at least three months apart or from age 12 months, two doses of MenQuadfi can be given at 8–12 weeks apart (a prescription is required for a MenQuadfi second primary dose, see note above). For children aged 12 months or older can receive either MenACWY vaccine for their second and subsequent doses. A booster dose is recommended after three years then five yearly.

Infants and 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 at least three months apart. 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 and children 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.

Infants 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 ‎13.5.1).

Measles or chickenpox exposure post-transplantation

Specialist advice should be sought if an individual who is immunosuppressed is a suspected or confirmed contact of a measles or chickenpox case. Post-transplantation, the use of passive immunisation with IG after exposure to measles or chickenpox should be based on the documentation of negative antibody titres, or where immune status is unknown. See Human normal immunoglobulin prophylaxis for contacts and Prophylaxis with intravenous immunoglobulin in section 12.8.2 and Post-exposure prophylaxis with zoster immunoglobulin in section 22.8.2.

4.3.5. Individuals receiving corticosteroids

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[40] 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.

Table 4.1: Guidelines for live vaccine administration for individuals receiving corticosteroid agents

Corticosteroid agent	Dose regime		Administration of live vaccines
Topical or local corticosteroid doses	Any agent, any dose applied to the skin inhaled injected locally into a joint, bursa or tendon		Any time before, during or after treatment
Budesonide	Oral or inhaled, any dose		Any time before, during or after treatment
Dexamethasone	Single dose for an acute respiratory illness		Any time before or after dose
	Physiological maintenance doses		Any time before, during or after treatment
	Long-term treatment not for physiological maintenance		Delay for 3 months after discontinuation
Fludrocortisone	Any dose		Delay for 3 months after discontinuation
Fluticasone	Oral or inhaled, any dose		Any time before, during or after treatment
Hydrocortisone	Physiological maintenance doses		Any time before, during or after dose
	Long-term treatment not for physiological maintenance		Delay for 3 months after discontinuation
Prednisone / Prednisolone[35]	Infants and children <10kg	Children and adults ≥10kg
	<2mg/kg per day, any duration	<20mg per day, any duration	Any time before, during or after treatment
	≥2mg/kg per day for <14 days	≥20mg per day for <14 days	Immediately on discontinuation
	≥2mg/kg per day for ≥14 days	≥20 mg per day for ≥14 days	Delay for 1 month after discontinuation

Note: The guidelines in this table are intended to ensure safety of administration of the live vaccines to individuals receiving corticosteroids; optimal vaccine immunogenicity may not be achieved.

COVID-19 vaccine

Children aged 6 months to 4 years receiving high-dose corticosteroids agents (see section ‎5.5.8 for details) are recommended to receive three doses of mRNA-CV (3 µg) (maroon cap). First and second doses are given at least 21 days apart and dose three is given at least eight weeks after the second dose. 

Certain individuals from 5 years of age receiving corticosteroids agents are eligible to receive a third primary dose of mRNA-CV (10 µg or 30 µg, as age appropriate) to be given at least 8 weeks after the second dose (see section 5.5.8 for details). A prescription is required for this use.

Regardless of any previous booster doses received after completion of the primary course, an additional dose of bivalent mRNA-CV (15/15 µg) is recommended to be given at least four to six months after previous dose for all individuals aged 12 years and over receiving corticosteroid agents, and in particular those eligible for a third primary dose. A dose given to anyone aged 12–15 years is considered an off-label use and will require prescription from an authorised provider (under regulation s25 of the Medicines Act 1981) (see section ‎5.5.10)

If a significant adverse reaction to mRNA-CV has occurred that contraindicates further mRNA-CV doses, then rCV may be given from age 18 years or age 12–17 years (off-label, requires a prescription), if not contraindicated: in this situation it is recommended to seek advice from IMAC.

4.3.6. Individuals receiving non-corticosteroid immunomodulatory agents

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.[42]

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.[42]

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.[42]

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.[42] 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.[42] 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 section 4.3.2.

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.
• Infants aged under 12 months born to mothers who received immunomodulatory biologic agents in pregnancy may also be temporarily immunocompromised (see section 4.3.6).

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

Table 4.2: Guidelines for live vaccine administration for individuals receiving non-corticosteroid agents

		Dose regime	Administration of live vaccines	Dose regime	Administration of live vaccines
Non-biologic agent
Hydroxychloroquine Mesalazine/5-ASA Olsalazine Sulfasalazine		Any dose	Any time before, during or after treatment
Azathioprine		≤3 mg/kg per day	Any time before, during or after treatment	>3mg/kg per day	Delay for 3 months after discontinuation
6-mercaptopurine		≤1.5 mg/kg per day		>1.5mg/kg per day
Methotrexate		≤0.4 mg/kg per week		>0.4mg/kg per week
Cyclophosphamide Cyclosporine Mycophenolate mofetil Tacrolimus				Any dose	Delay for 3 months after discontinuation
Leflunomide Teriflunomide				Any dose	Delay for 6 months after discontinuation
Axitinib Imatinib Ruxolitinib Tofacitinib				Any dose	Delay for 12 months after discontinuation
Biologic agent
Locally injected biologic dose		Any agent, any dose Intra-ocular injection	Any time before, during or after dose
Omalizumab Mepolizumab		Any dose	Any time before, during or after dose
Fingolimod Natalizumab				Any dose	Delay for 3 months after discontinuation
Atezolizumab Ipilimumab Nivolumab Pembrolizumab Sirolimus				Any dose	Delay for 6 months after discontinuation
Abatacept Adalimumab Anakinra Etanercept Infliximab Rituximab Tocilizumab Trastuzumab				Any dose	Delay for 12 months after discontinuation
Ocrelizumab				Any dose	Delay for 3 years after discontinuation

For children aged under 18 years, see the Starship Clinical Guidelines Immunosuppression and Immunisation in Rheumatology.

For adults, see the IMAC factsheet Immunisation for adults with immune-mediated inflammatory disease (IMID) who require immunosuppressive treatment (available on the IMAC website).

COVID-19 vaccine

Children aged 6 months to 4 years receiving certain biologic and non-biologic immunosuppressive agents (see section ‎5.5.8 for details) are recommended to receive three doses of mRNA-CV (3 µg) (maroon cap). First and second doses are given at least 21 days apart and dose three is given at least eight weeks after the second dose. 

Individuals from 5 years of age receiving certain biologic and non-biologic immunosuppressive agents are eligible to receive a third primary dose of mRNA-CV (10 µg or 30 µg, as age appropriate) to be given at least 8 weeks after the second dose (see section 5.5.8 for details). A prescription is required for this use.

Regardless of any previous booster doses received after completion of the primary course, an additional dose of bivalent mRNA-CV (15/15µg) is recommended to be given four to six months after previous dose for all individuals aged 12 years and over receiving immunosuppressive agents, and in particular those eligible for a third primary dose. A dose given to anyone aged 12–15 years is considered an off-label use and will require prescription from an authorised provider (under regulation s25 of the Medicines Act 1981) (see section ‎5.5.10)

If a significant adverse reaction to mRNA-CV has occurred that contraindicates further mRNA-CV doses, then rCV may be given from age 18 years or age 12–17 years (off-label, requires a prescription), if not contraindicated: in this situation it is recommended to seek advice from IMAC.

Infants of mothers who received immunomodulatory biologic agents during pregnancy

In recent years there has been rapid development of targeted immunomodulatory biologic agents (also known as biologic response modifiers; BRM), and an increasing number of pregnant women are receiving such therapies. Common examples include adalimumab, infliximab and rituximab. Studies of the effects of these agents on the infant’s immune system and ability to respond to vaccination are limited.[43]

Multiple factors influence the potential for these agents to be detected and/or cause immunosuppression in an infant for months after they are born. These include, the agent or combination of agents used, gestational age(s) when administered, ability of the agent(s) and/or their metabolites to cross the placenta, and time between administration of the last antenatal dose and the chronological age of the infant.[44]

A recent study analysing a US vaccine safety database is encouraging regarding the safety of rotavirus vaccine in the first year of life, and measles-containing vaccine in the first two years of life, in infants exposed in utero to immunomodulatory biologic agents, with no increased rates of adverse events.[45] The commonest agents represented were anakinra, adalimumab, infliximab and etanercept, but other agents were only used in a few women so the safety of these remains unknown.

Rotavirus vaccine

There is limited data on rotavirus vaccination safety when given to infants born to mothers receiving immunomodulatory therapy during pregnancy.[20, 43, 46] Although in most cases it is likely to be safe, caution is required. The level of circulating wild-type rotavirus is currently very low in New Zealand, therefore, the risk of gastroenteritis following rotavirus vaccination in this cohort of infants may be greater than the risk of acquiring the disease. The decision to administer rotavirus vaccine to infants born to mothers who received immunomodulatory biologic agents during pregnancy should be determined case by case.

If an infant turns 15 weeks of age before the first rotavirus vaccine dose can be administered, they will not be able to receive any rotavirus vaccine doses.

BCG

Infants born to mothers who received immunomodulatory biologic agents during pregnancy must not be vaccinated with a BCG vaccine without specialist consultation (see box above). 

MMR and VV

Infants aged under 12 months born to mothers who received immunomodulatory biologic agents during pregnancy should not be vaccinated with MMR or VV unless specialist consultation has been sought. Normally, it is only recommended to give MMR and VV before age 12 months if there is an increased risk of exposure, such as during an outbreak or following close contact with a case (see sections 12.5.1, 12.8 and 22.8.3) or if an infant is on an accelerated vaccination schedule prior to solid organ transplantation (see section 4.3.11).

4.3.7. Vaccination prior to planned immunosuppression

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 be given safely when receiving immunosuppression, the immune response is likely to be reduced.
• Administration of non-live vaccines (eg, completion of meningococcal vaccines) can resume 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 with immune-mediated inflammatory disease (IMID) who require immunosuppressive treatment (available on the IMAC website).

Table 4.3: Additional vaccine recommendations for children (12 months to 18 years) when diagnosed with a condition requiring immunosuppression for than 28 days or longer, or having completed immunosuppression
Refer to the Pharmaceutical Schedule for any changes to funding decisions. Children should receive the usual Schedule vaccines, including rotavirus vaccine for infants prior to planned immunosuppression.

Relevant age	Vaccine (trade name)	Recommended vaccination schedule
Ages 12 months to 18 years when diagnosed with a condition requiring immuno-suppression	PCV13	Children aged 12–59 months, who have not yet received any PCV13 give 2 doses of PCV13 at least 8 weeks aparta Children aged 5 years to under 18 years: give 1 dose of PCV13 even if fully vaccinateda
	23PPV (Pneumovax 23)	Following completion of the PCV schedule, give 1 dose at least 8 weeks after the last PCV13 dose, from age 2 years.b Revaccinate once after 5 years.
	MenACWY  (Menactra or MenQuadfi)b	If aged 12 months to under 7 years at diagnosis, give 2 dosesc of MenACWY 8-12 weeks apart followed by a booster dose after 3 years, then 5‑yearlyd If aged 7 years or older give 2 dosesc of MenACWY 8 weeks apart followed by a booster dose 5-yearlyd
	MenB (Bexsero)e	For children aged from 12 to 23 months, who have not yet received any MenB, give 2 doses 8 weeks apart. Give a booster dose 12–23 months after second dose. From age 2 years, give 2 doses 8 weeks apart (or reduced to 4 weeks apart, if clinically necessary). Give booster doses 5-yearlyf
	Hib-PRP-T (Hiberix)	For children aged from 12 to 23 months, who have not yet received any MenB, give 2 doses 8 weeks apart. Give a booster dose 12–23 months after second dose. If aged 16 months to under 5 years and has not received a single Hib-PRP-T dose after age 12 months, give 1 dose. If aged 5 years or older, give 1 dose, unless fully vaccinated.
	Influenza (age-appropriate vaccine)g	Give annually. In previously unvaccinated children age <9 years, give 2 doses 4 weeks apart, then 1 dose in each subsequent year.
	MMR	2 doses given 4 weeks apart, if time permits, to be given at least 4 weeks prior to planned immunosuppression.h
	Varicella (VV)	2 doses given 4 weeksh apart, if time permits, and to be given at least 4 weeks prior to planned immunosuppression.i
	COVID-19 (mRNA-CV)	Ensure individual is up to date with age-appropriate vaccine and schedule, see Table ‎5.1

1. There are no safety concerns, regardless of the interval between the last dose of PCV10 and the first dose of PCV13.
2.  If 23PPV has already been given (prior to any doses of PCV13) to children aged under 18 years, wait at least 8 weeks before administering PCV13 (note – this differs from a 1-year gap recommended in adults).
3. A prescription is required for a second primary dose of MenQuadfi for those aged 12 months and over or Menactra for those aged 2 years and over.
4. Where possible give MenACWY-D (Menactra) at least 4 weeks after PCV13 (see section ‎4.3.3).  PCV13 and MenACWY-D can be given together or at any interval for pragmatic reasons or if an accelerated schedule is required (see section ‎4.3.3). MenQuadfi (or Nimenrix) can be offered at any time together or after PCV13.
5. It is recommended to administer prophylactic paracetamol (or ibuprofen) to reduce fever in children age under 2 years (see section ‎13.7.3).
6. Although, the need for a booster dose after this vaccination schedule has not been established, it is recommended and funded for certain special groups.
7. Check Influenza website for most recent influenza vaccine brands and appropriate age ranges.
8. Live viral vaccines are recommended to be administered prior to planned immunosuppression. Clinically indicated immunosuppression should not be delayed in order to give live vaccines.
9. Accelerated timing for VV differs from Table ‎22.1. For vaccination after immunosuppression, standard interval of 6 weeks would apply.

4.3.8. (Re)vaccination following immunosuppression

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.

4.3.9. Oncology

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 section 4.3.2).

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 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 (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 post-chemotherapy who are not taking immunosuppressive disease modifying drugs (available on the IMAC website).

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]

4.3.10. Haematopoietic stem cell transplantation

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

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 at least 21 days apart and dose three is given at least eight weeks after the second dose. 

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

A third primary dose of mRNA-CV (10 µg or 30 µg, as age appropriate), to be given at least 8 weeks after dose two, is available for 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 ‎5.5.8 for details). A prescription is required for this use.

Regardless of any previous booster doses received after completion of the primary course, an additional dose of bivalent mRNA-CV (15/15µg) is recommended to be given four to six months after previous dose for all individuals aged 12 years and over for recipients of HSCT, and in particular those eligible for a third primary dose. A dose given to anyone aged 12–15 years is considered an off-label use and will require prescription from an authorised provider (under regulation s25 of the Medicines Act 1981) (see section ‎5.5.10). 

If a significant adverse reaction to mRNA-CV has occurred that contraindicates further mRNA-CV doses, then rCV may be given from age 18 years or age 12–17 years (off-label, requires a prescription), if not contraindicated: in this situation it is recommended to seek advice from IMAC.

4.3.11. Solid organ transplantation

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.

COVID-19 vaccine

Children aged 6 months to 4 years receiving or having received immunosuppressive therapy following a solid organ transplant are recommended to receive three doses of mRNA-CV (3 µg) (maroon cap). First and second doses are given at least 21 days apart and dose three is given at least eight weeks after the second dose. 

A third primary dose of mRNA-CV (10 µg or 30 µg, as age appropriate), to be given at least 8 weeks after dose two, is available for individuals aged from 5 years receiving or having received immunosuppressive therapy following a solid organ transplant (see section 5.5.8 for details). A prescription is required for this use.

Regardless of any previous booster doses received after completion of the primary course, an additional dose of bivalent mRNA-CV (15/15µg) is recommended to be given four to six months after previous dose for all individuals aged 12 years and over following a solid organ transplant, and in particular those eligible for a third primary dose. A booster dose given to anyone aged 12–15 years is considered an off-label use and will require prescription from an authorised provider (under regulation s25 of the Medicines Act 1981) (see section ‎5.5.10)

Based on clinical discretion, if all scheduled doses have been completed prior to commencement of chemotherapy or solid organ transplant, a single further dose of mRNA-CV can be given from the age of 5 years.

If a significant adverse reaction to mRNA-CV has occurred that contraindicates further mRNA-CV doses, then rCV may be given from age 18 years or age 12–17 years (off-label, requires a prescription), if not contraindicated: in this situation it is recommended to seek advice from IMAC.

Live vaccines – caution

Live vaccines should also be administered at least four weeks before a predicted transplant. Administration of live vaccines (MMR and VV) is generally contraindicated post-transplantation due to immunosuppression. However, 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.[38] With specialist input MMR may also be considered in clinically well patients at least 1 year after solid organ transplantation on low level immunosuppression.

See Vaccines for individuals with acquired immunodeficiency in section 4.3.4 for precautions and contraindications for the administration of live vaccines (MMR and VV), eligibility and recommendations for influenza, Hib, pneumococcal and meningococcal vaccines, and recommendations when an individual who is immunosuppressed/post-solid organ transplantation is a contact of a measles or chickenpox case.

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.

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

Table 4.4: Accelerated vaccination schedule with additional vaccine recommendations for infants likely to require liver or kidney transplantation
Funded vaccines are in shaded rows. Refer to the Pharmaceutical Schedule for any changes to funding decisions.

Age	Vaccination	Comments
Do not start earlier than age 6 weeks.
6 weeks	RV1 (Rotarix) PCV13a (Prevenar 13) DTaP-IPV-HepB/Hib (Infanrix‑hexa)	It is preferable to not give RV1 within 4 weeks of predicted transplant
2 months	MenB (Bexsero)b MenC (NeisVac-C)	If MenACWY-T (Nimenrix) not given
	MenACWY-T (Nimenrix)c	Not fundedc; needs to be prescribed and purchased
3 months	RV1 PCV13 (Prevenar 13) DTaP-IPV-HepB/Hib (Infanrix‑hexa)	It is preferable to not give RV1 within 4 weeks of predicted transplant
4 months	MenB (Bexsero)b MenC (NeisVac-C)	If MenACWY-T (Nimenrix) not given
	MenACWY-T (Nimenrix)c	Not fundedc; needs to be prescribed and purchased
5 months	PCV13 (Prevenar 13) DTaP-IPV-HepB/Hib (Infanrix‑hexa)
6 months	Influenza (junior formulation)d	Give two doses 4 weeks apart in the first year receiving influenza vaccine, and one dose in subsequent years Give annually
	MMR (Priorix)e	MMR should not be given less than 4 weeks before the predicted transplant
	HepA (Havrix Junior)	Liver transplant only
	Check Anti-HBs serology	If anti-HBs is negative, give a further three doses of monovalent HepB vaccine (Engerix-B 20 µg) 4 weeks apart
From 6 months	COVID-19 (mRNA-CV (3 µg))	Give two doses 3 weeks apart then a third dose 8 weeks (minimum 4 weeks) later
9 months	Varicella (Varilrix)e,f	In general, VV should not be given less than 4 weeks before the predicted transplant but may be given closer at the discretion of the specialist
	MenACWY-D (Menactra)g	If MenACWY-T (Nimenrix) not given previously
12 months	PCV13 (Prevenar 13)a
	MMRe	MMR should not be given less than 4 weeks before the predicted transplant
	Varicella (Varivax)e	In general, VV should not be given less than 4 weeks before the predicted transplant but may be given closer at the discretion of the specialist
	MenB (Bexsero)b	At least 6 months after second dose, give 1 dose to those who received two primary doses in infancy, followed by booster dose 5-yearly If previously unvaccinated, give 2 doses 8 weeks apart, then a booster 12–23 months after dose two followed by booster doses given 5-yearly
13 months	DTaP-IPV-HepB/Hib (Infanrix-Hexa)
	MMR (Priorix)	MMR should not be given less than 4 weeks before the predicted transplant
	MenACWY (Menactra or MenQuadfi)g,h	Give 1 doseh of MenACWY if previously received ≥1 dose of MenACWY If previously unvaccinated with MenACWY, give 2 doses 8 weeks apart Give a booster after 3 years, then 5-yearly
	HepA (Havrix Junior)
2 years	23PPV (Pneumovax 23)	Give one dose Revaccinate once after 5 years
4 years	DTaP-IPV (Infanrix-IPV)
From age 9 years	HPV9 (Gardasil 9)	Give 3 doses at 0, 2 and 6 months
11 years	Tdap (Boostrix)
6 months post-transplant	HepB (Engerix-B), plus anti-HBs serology before and 4 weeks after the initial HepB series	Give 3 doses of monovalent HepB vaccine (Engerix-B 20 ug) If there is an inadequate immune response to the initial 3‑dose HepB series, give a further 3 doses
	23PPV (Pneumovax 23)	If child is at least 24 months old and dose not given pre-transplant Revaccinate once after 5 years
	Influenza (age appropriate vaccine)d	For infants and children aged 6 months to under 9 years, give 2 doses 4 weeks apart in the first year of receiving the influenza vaccine, and 1 dose in subsequent years Give annually
12 months post-transplant	Resume the usual Schedule, except live vaccines	Live vaccinesi are contraindicated post-transplantation
Household contacts of transplant recipients	National Immunisation Schedule vaccines	Immune-competent siblings and other household contacts may receive all the Schedule vaccines and should be fully vaccinated for their age.
	COVID-19	All household contacts should receive age-appropriate vaccination according to the recommended schedule (see Table ‎5.2).
	Influenza (with age-appropriate vaccine)d	Recommended annually for all family membersj.
	Varicella	Two doses of VV are funded for susceptible household contacts of transplant recipients.

4.3.12. Functional asplenia, hyposplenia and pre-/post-splenectomy

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 4.3.4 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.

Table 4.5: Additional vaccine recommendations for infants and children aged under 18 years with functional or anatomical asplenia
Funded vaccines are in the shaded rows. Refer to the Pharmaceutical Schedule for any changes to funding decisions.

Relevant age	Vaccine (trade name)		Recommended vaccination schedule
Under 12 months when diagnosed with functional asplenia or pre- or post-splenectomya	PCV13 (Prevenar 13)b		Give PCV13b at ages 6 weeks, and 3, 5 and 12–15 months or an age-appropriate catch-up schedule: If aged under 7 months, give PCV13b at ages 6 weeks, 3 months, 5 months and 12 months For those who have not been immunised age 7–11 months: give 2 doses of PCV13 (8 weeks apart) and a further dose at least 8 weeks later, from age 12 months For children aged 7–11 months who have completed a 2‑dose primary course with PCV10, give 1 dose of PCV13 as soon as possible and another dose (of PCV13) at least 8 weeks later, from age 12 months
	23PPV (Pneumovax 23)		Following completion of the PCV schedule, give 1 dose at least 8 weeks after the last PCV13 dose, from age 2 years Revaccinate once after 5 years
	MenC (NeisVac-C) and MenACWY-D (Menactra)c		If aged under 9 months, give 2 doses of MenC 8 weeks apart, followed by MenACWY-Dc at ages 9 and 13 months. Administer one MenACWY-D booster dose after 3 years, then 5‑yearly. See alternative unfundedc MenACWY-T (Nimenrix) option below If aged 9–11 months, give 2 doses of MenACWY-Dc at least 3 months apart, followed by a booster dose after 3 years, then 5-yearly The second dose and subsequent doses can be MenQuadfi once aged over 12 months.
	MenB (Bexsero)d		Give one dose at age 8 weekse, 4 months and 12 months Or give two doses at least 8 weeksf apart and a booster dose at least 6 months later, from age 12 months Give a booster dose 5-yearly.
	MenACWY (Nimenrix)g		Licensed from 6 weeks; can be used in place of MenC doses to offer broader protection. Not fundedg; needs to be prescribed and purchased. Give 2 doses at least 8 weeks apart. A booster dose of MenACWYc (Menactra or MenQuadfi funded) or MenACWY-T (unfunded) is recommended at age 12 months or older
	Influenza (junior formulation)h		Annual vaccination from age 6 months. In the first year, give 2 doses 4 weeks apart, then 1 dose in each subsequent year
	COVID-19 (mRNA-CV 3 µg)		From age 6 months, give two doses 3 weeks apart and a third dose 8 weeks later.
Aged 12 months to under 18 years when diagnosed with functional asplenia or pre- or post-splenectomya	PCV13		Children aged 12–59 months, who have not yet received any PCV13: give 2 doses of PCV13 at least 8 weeks aparti Children aged 5 years to under 18 years: give 1 dose of PCV13 even if fully vaccinatedj
	23PPV (Pneumovax 23)		Following completion of the PCV schedule, give 1 dose at least 8 weeks after the last PCV13 dose, from age 2 years. Revaccinate once after 5 years.
	MenACWY  (Menactra or MenQuadfi)c		If aged 12 months to under 7 years at diagnosis, give 2 dosesk of MenACWY 8–12 weeks apart followed by a booster dose after 3 years, if still aged under 7 years, then 5‑yearlyc If aged 7 years or older give 2 dosesk of MenACWY 8 weeks apart followed by a booster dose 5-yearlyc
	MenB (Bexsero)d		From age 12 to 23 months, give 2 doses 8 weeksk apart followed by a booster given 12–23 months after second dose. From age 2 years, give 2 doses 8 weeksk apart. Give booster doses 5-yearlyl.
	Hib-PRP-T (Hiberix)		If child is aged 12–15 months, give 1 dose at age 15 months as per the Schedule If aged 16 months to under 5 years and has not received a single Hib-PRP-T dose after age 12 months, give 1 dose If aged 5 years or older, give 1 dose, unless fully vaccinated
	Influenza (age appropriate vaccine)g		Give annually In previously unvaccinated children age <9 years, give 2 doses 4 weeks apart, then 1 dose in each subsequent year
	COVID-19 (mRNA-CV)		Ensure individual is up to date with age-appropriate vaccine and schedule, see Table ‎5.1

4.3.13. HIV infection

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.

COVID-19 vaccine

Children aged 6 months to 4 years with active HIV infection or AIDS (with CD4 count <200 cells per µl) are recommended to receive three doses of mRNA-CV (3 µg) (maroon cap). First and second doses are given at least 21 days apart and dose three is given at least eight weeks after the second dose. 

Individuals aged from 5 years with active HIV infection or AIDS (with CD4 count <200 cells per µl) are eligible to receive a third primary dose of mRNA-CV (10 µg or 30 µg, as age appropriate) to be given at least 8 weeks after the second dose (see section 5.5.8 for details). A prescription is required for this use.

Regardless of any previous booster doses received after completion of the primary course, an additional dose of bivalent mRNA-CV (15/15µg) is recommended to be given four to six months after previous dose for all individuals aged 16 years and over living with HIV infection, and in particular those eligible for a third primary dose. A dose given to anyone aged 12–15 years is considered an off-label use and will require prescription from an authorised provider (under regulation s25 of the Medicines Act 1981) (see section ‎5.5.10)

If a significant adverse reaction to mRNA-CV has occurred that contraindicates further mRNA-CV doses, then rCV may be given from age 18 years or age 12–17 years (off-label, requires a prescription), if not contraindicated: in this situation it is recommended to seek advice from IMAC.

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]

Live zoster vaccine has been discontinued. Individuals from age 18 years with HIV infection are recommended two doses (unfunded) of recombinant zoster vaccine (rZV, Shingrix). See section 23.5.1.

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.

Table 4.6: Additional vaccine recommendations for children aged under 5 years when diagnosed with HIV
Note: HIV-positive children should receive the usual Schedule vaccines, including rotavirus vaccine for infants; BCG should not be given; MMR and VV may be administered as per the recommendations below. Funded vaccines are in shaded rows. Refer to the Pharmaceutical Schedule for any changes to funding decisions.

Relevant age		Vaccine (trade name)	Recommended vaccine schedule
Infants aged under 12 months when diagnosed		PCV13 (Prevenar 13)a	Give PCV13a at ages 6 weeks and 3, 5 and 12–15 months or an age-appropriate catch-up schedule: If aged under 7 months, give PCV13a at ages 6 weeks, 3 months, 5 months and 12 months For those who have not been immunised age 7–11 months: give two doses of PCV13 (8 weeks apart) and a further dose at least 8 weeks later, from age 12 months For children aged 7–11 months who have completed a 2‑dose primary course with PCV10, give 1 dose of PCV13 as soon as possible and another dose (of PCV13) at least 8 weeks later, from age 12 months
		23PPV (Pneumovax 23)	Following completion of the PCV schedule, give one dose at least 8 weeks after the last PCV13 dose, from age 2 years Revaccinate once after 5 years
		MenC (NeisVac-C) and MenACWY-D (Menactra)b	If aged under 9 months, give 2 doses of MenC 8 weeks apart, followed by MenACWY at ages 9 and 13 monthsb Administer one MenACWY-D booster dose after 3 years, then 5-yearly See alternative unfunded MenACWY-T (Nimenrix) option belowc If aged 9–11 months, give 2 doses of MenACWY-Db at least 3 months apart, followed by a booster dose after 3 years, then 5-yearly. The second dose and subsequent doses can be MenQuadfi once aged over 12 months.
		MenB (Bexsero)d	Give one dose at age 8 weekse, 4 months and 12 months Or give two doses at least 8 weeksf apart and a booster dose at least 6 months later, from age 12 months
		MenACWY-T (Nimenrix)	Licensed from age 6 weeks, can be used in place of MenC doses. Not fundedc; needs to be prescribed and purchased. Give 2 doses at least 8 weeks apart A booster dose of MenACWY (Menactra or MenQuadfi)b (funded) or MenACWY-T (Nimenrix, unfunded) is recommended at age 12 months or older
		Influenza (junior formulation)g	Annual vaccination from age 6 months In the first year, give 2 doses 4 weeks apart, then 1 dose in each subsequent year
		COVID-19 (mRNA-CV (3µg))	From age 6 months, give two doses 3 weeks apart and a third dose 8 weeks later.
Children aged 12 months to under 5 years when diagnosed		PCV13	Children aged 12–59 months, who have not yet received any PCV13, give 2 doses of PCV13 at least 8 weeks aparth Children aged 5 years to under 18 years, give 1 dose of PCV13 even if fully vaccinatedi
		23PPV (Pneumovax 23)	Following completion of the PCV schedule, give 1 dose at least 8 weeks after the last PCV13 dose, from age 2 years Revaccinate once after 5 years
		Influenza (age appropriate vaccine)g	Give annually In previously unvaccinated children, give 2 doses 4 weeks apart, then 1 dose in each subsequent year.
		MMRj (Priorix)	If CD4+ lymphocyte percentage is ≥15%: give the first MMR dose at age 12 months, followed by the 2nd dose 4 weeks later
		Varicellaj (Varivax)	If CD4+ lymphocyte percentage is ≥15%: give 2 doses (starting 4 weeks after the 2nd MMR), at least 3 months apart
		MenACWYb (Menactra or MenQuadfi)	Give 2 doses of MenACWYk 8 to 12 weeks apart followed by a booster dose after 3 years, if still aged under 7 years, then 5 yearlyb
		MenB (Bexsero)d	From age 12 to 23 months, give 2 doses 8f weeks apart followed by a booster given 12–23 months after second dose. From age 2 years, give 2 doses 8f weeks apart Give booster doses 5-yearlyj.
		COVID-19 (mRNA-CV (3µg))	Give two doses 3 weeks apart and a third dose 8 weeks later.

Table 4.7: Additional vaccine recommendations for children aged 5 to under 18 years when diagnosed with HIV
Note: HIV-positive children should receive the usual Schedule vaccines, MMR and varicella vaccines may be administered as per the recommendations below. Funded vaccines are in shaded rows. Refer to the Pharmaceutical Schedule for any changes to funding decisions.

Vaccine (trade name)	Recommended vaccine schedule
HPV9 (Gardasil 9)a	From age 9 years, give 3 doses of HPV at 0, 2 and 6 monthsa
PCV13 (Prevenar 13)b	For children who have not previously received PCV13, give 1 dose of PCV13b
23PPV (Pneumovax 23)	Give 1 dose of 23PPV at least 8 weeks after the PCV13 dose. Revaccinate once with 23PPV, 5 years after the first 23PPV
MenACWY (Menactra or MenQuadfi)c	If aged 5 years to under 7 years give 2 doses of MenACWY 8 to 12 weeks apart followed by a booster dose after 3 years and then 5-yearlyc If aged 7 years or older give 2 doses of MenACWY 8 to 12 weeks apart followed by a booster dose 5-yearlyc
MenB (Bexsero)	Give 2 doses 8e weeks apart followed by a boosterf dose 5-yearly.
MMRd (Priorix)	If aged ≤13 years and CD4+ lymphocyte percentage is ≥15%, or if aged ≥14 years and CD4+ lymphocyte count is ≥200 cells/mm3: give 2 doses of MMR at least 4 weeks apart
Varicellad (Varivax)	If no history of varicella disease or vaccination, and if aged ≤13 years and CD4+ lymphocyte percentage is ≥15%, or if aged ≥14 years and CD4+ lymphocyte count is ≥200 cells/mm3: give 2 doses (starting 4 weeks after 2nd MMR) at least 3 months apart
Influenza (Afluria Quad)	If aged under 9 years give 2 doses 4 weeks apart in the first year receiving influenza vaccine (both doses are funded), and 1 dose in subsequent years If aged 9 years or older give 1 dose Give annually
COVID-19 (Comirnaty)	Two doses given 8 weeks apart (minimum 21 days apart) from age 5–11 years (mRNA-CV 10 µg) or from age 12 years (mRNA-CV 30 µg) A booster dose and additional doses (mRNA-CV 15/15 µg) can be offered 4-6 months after the previous dose (ages 12–15 years off-label, requires prescription).

4.4. Chronic kidney disease

Individuals immunised during the early stages of chronic kidney disease (CKD) generally respond to vaccination. However, the immune system response to vaccination decreases with advancing kidney disease.[58, 59] Cases of children developing a disease for which they have serological evidence of immunity have been reported.[59]

Individuals with nephrotic syndrome, kidney failure or end-stage kidney disease (CKD stages 4–5) have an increased risk of peritonitis and/or sepsis caused by encapsulated bacteria, Streptococcus pneumoniae, Haemophilus influenzae type b and Neisseria meningitidis.[58, 59, 60] Individuals on haemodialysis have an increased risk of exposure to hepatitis B virus. Adults with CKD also have an increased risk of zoster.[61]

Vaccination of individuals with chronic kidney disease

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).

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.

Live vaccines – caution

Administration of live vaccines (MMR and VV or ZV) are generally contraindicated for individuals who are immunosuppressed because of the risk of disseminated vaccine disease. However, individuals with CKD who are considered to have minimal immunosuppression may be able to receive VV.[41]

Live zoster vaccine has been discontinued. Two doses of recombinant zoster vaccine (rZV, Shingrix) are recommended for adults with CKD stages 4–5 from age 18 years (unfunded).

See Vaccines for individuals with acquired immunodeficiency in section 4.3.4 for eligibility and recommendations for influenza, Haemophilus influenzae type b (Hib), pneumococcal and meningococcal vaccines.

There is no relationship between vaccination and deterioration of renal function or a reduction in the efficacy of dialysis.[59]

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

COVID-19

Children aged 6 months to 4 years receiving long term haemodialysis or peritoneal dialysis are recommended to receive three doses of mRNA-CV (3 µg) (maroon cap). First and second doses are given at least 21 days apart and dose three is given at least eight weeks after the second dose. 

Individuals from 5 years of age receiving long term haemodialysis or peritoneal dialysis are eligible to receive a third primary dose of mRNA-CV (10 µg or 30 µg) to be given at least 8 weeks after the second dose. A prescription is required for this use (see section 5.5.8 for details).

Regardless of any previous booster doses received after completion of the primary course, an additional dose of bivalent mRNA-CV (15/15µg) is recommended to be given four to six months after previous dose for all individuals aged 16 years and over with chronic kidney disease, and in particular those eligible for a third primary dose. A given to anyone aged 12–15 years is considered an off-label use and will require prescription from an authorised provider (under regulation s25 of the Medicines Act 1981) (see section ‎5.5.10)

If a significant adverse reaction to mRNA-CV has occurred that contraindicates further mRNA-CV doses, then rCV may be given from age 18 years or age 12–17 years (off-label, requires a prescription), if not contraindicated: in this situation it is recommended to seek advice from IMAC.

4.5. Chronic liver disease

Chronic liver disease in infants and children may present as part of a congenital syndrome. They may have other conditions (eg, infants with biliary atresia may also have a non-functioning spleen) and eligibility for additional funded vaccines.

4.5.1. Vaccination of individuals with chronic liver disease

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 4.3.1).

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 4.3.11).

4.6. Other special groups

It is recommended that all individuals receive vaccination as per the usual Schedule except when pre-vaccination screening identifies a contraindication for a specific vaccine (see section 2.1.4). Additional vaccines may be recommended (but are not always funded) for individuals with some conditions or in some circumstances not previously discussed in this chapter. Table 4.8 lists other special groups and recommended additional vaccines. Funded vaccines are shown in shaded rows.

Table 4.8: Additional vaccine recommendations for other special groups
Funded vaccines are in shaded rows. See the table footnotes for more information when indicated. Vaccinators are advised to check the Pharmaceutical Schedule for any changes to funding decisions.

Special group			Recommended vaccines
Individuals:
with cerebrospinal fluid (CSF) leak			Children, aged under 5 years PCV13, 23PPV Influenza, annually mRNA-CV (3 µg) (excluding asthma) Children aged 5 years to under 18 years, (including for those who received previous doses of a non-PCV13 vaccine (PCV10 and PCV7) PCV13, 23PPV Influenza, annually mRNA-CV (10 µg)
chronic pulmonary disease, including asthma treated with high-dose corticosteroid therapy, and cystic fibrosis receiving corticosteroid therapy for more than two weeks and who are on an equivalent daily dosage of prednisone of 2 mg/kg per day or greater, or children who weigh more than 10 kg on a total daily dosage of 20 mg or greater diabetes intracranial shunt receiving radiotherapy
living in boarding schools, hostels, university halls of residence, or other close quartersa			MenACWYa MMR (if susceptible) MenBa
			Hepatitis B (if susceptible) VV (if susceptible) Influenza, annually
with cochlear implants			Haemophilus influenzae type b (Hib-PRP-T) Influenza, annually Pneumococcal (PCV13, 23PPV)
living in correctional facilitiesa			MenACWYa MMR (if susceptible) MenBa
			Hepatitis B (if susceptible) Influenza, annually
with error of metabolism at risk of major metabolic decompensation			Influenza, annually Varicella (VV)
with rheumatic heart disease			Influenza, annually
who are case contacts of an individual with hepatitis A			Hepatitis A (if susceptible)
with hepatitis B infection			Hepatitis A (if susceptible)
who are household or sexual contacts of an individual with hepatitis B			Hepatitis B (if susceptible)
with hepatitis C infection			Hepatitis A (if susceptible) Hepatitis B (if susceptible)
with a needle-stick injury			Hepatitis B (if susceptible)
who have had non-consensual sexual intercourseb			Hepatitis B (if susceptible)
Intravenous drug users			Hepatitis A (if susceptible) Hepatitis B (if susceptible) Influenza, annually
Men who have sex with menb			HPVc
			Hepatitis A (if susceptible) Hepatitis B (if susceptible)
Case contacts of an individual with meningococcal disease of any group			MenACWYd MenB
Individuals who have previously had meningococcal disease of any group			MenACWYd MenB
Children at risk of exposure to tuberculosis			BCG vaccination for children aged under 5 years who: will be living in a house or family/whānau with a person with either current TB or a history of TB have one or both parents or household members or carers who within the last five years lived for a period of six months or longer in countries with a TB rate ≥40 per 100,000 during their first five years will be living for three months or longer in a country with a TB rate ≥40 per 100,000. See section 21.5.2

4.7. Immigrants and refugees

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 Ministry of Health 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 21.5.2 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 21.3.2 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 21.4). If there is no history of chickenpox, VV should be offered (although it is currently not funded).

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], or adjuvanted rCV from age 12 years), regardless of health and disability services eligibility. First booster dose and additional doses are available from age 16 years with mRNA-CV (15/15 µg). See section ‎5.5.3 for timing of COVID-19 vaccination following prior COVID-19 infection. For information about up to date COVID-19 vaccination in relation to documented partial immunisation with different vaccines given elsewhere see COVID-19: Overseas vaccinations and My Vaccine Pass.

 

4.8. Occupation-related vaccination

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.

Table 4.9: Recommended vaccines, by occupational group

Occupation			Recommended vaccines
Workers in health care settings
Health care staff who work with patients or are working in clinical areas where patient care is being administered For example, medical staff, nursing staff, lead maternity carers, radiography staff, dentists, other health professional staff and students, and allied staff in health care settings, such as cleaning and catering staff			Tdap – at least every 10 yearsa MMR Varicella Hepatitis B Influenza, annually COVID-19
Carers
Health care assistants, long-term facility carers and nursing home staff			Tdap – at least every 10 yearsa MMR Varicella Hepatitis B Influenza, annually COVID-19
Individuals who work with children
Early childhood education services staff			Tdap – at least every 10 yearsa IPV MMR Varicella Hepatitis A Hepatitis B Influenza, annually COVID-19
Other individuals working with children, including: correctional staff working where infants/children live with mothers school teachers (including student teachers) outside school hours carers child counselling services workers youth services workers			Tdap – at least every 10 yearsa IPV MMR Varicella Influenza, annually COVID-19
Emergency and essential service workers
Police and emergency workers			Tdap – at least every 10 yearsa IPV MMR Varicella Hepatitis B Influenza, annually COVID-19
Armed forces personnel			Tdap – at least every 10 yearsa IPV MMR Varicella Hepatitis A (if deployed to high-risk countries) Hepatitis B Influenza, annually COVID-19 MenB (if living in close quarters) MenACWYb (if living in close quarters and/or deployed to high-risk countries) Yellow fever, rabies, typhoid, Japanese encephalitis (as appropriate, if deployed to high-risk countries)
Staff of correctional facilities			Tdap – at least every 10 yearsa IPV MMR Varicella Hepatitis B Influenza, annually COVID-19
Staff of immigration/refugee centres			Tdap – at least every 10 yearsa IPV MMR Varicella Hepatitis B Influenza, annually COVID-19
Border staff and those working in managed quarantine facilities (eg, cleaners, security staff, custom and border officials, hotel workers, airline staff, port authorities, police, defence force staff and health professionals)			Influenza, annually MMR COVID-19
Individuals who work with animals
Veterinarians, veterinary students and veterinary nurses			Tdap IPV MMR Influenza, annually
Zoo staff who work with primates			Tdap IPV MMR Hepatitis A Influenza, annually
Poultry workers and others handling poultry, including those who may be involved in culling during an outbreak of avian influenza, and swine industry workers			Tdap IPV MMR Influenza, annually
Individuals exposed to human tissue, blood, body fluids or sewage
Laboratory staff			Tdap MMR Varicella Hepatitis A (if exposed to faeces) Hepatitis B Influenza, annually MenACWY and MenB (if regularly working with Neisseria meningitidis cultures) IPV (10-yearly booster doses if handling faecal samples from those coming from high-risk countries) COVID-19
Workers who perform skin penetration procedures (eg, tattooists, body-piercers)			Tdap IPV Hepatitis B
Funeral workers, embalmers and other workers who have regular contact with human tissue, blood or body fluids and/or used needles or syringes
Sewage workers, plumbers or other workers in regular contact with untreated sewage			Tdap IPV MMR Hepatitis A Hepatitis B
Sex workersc			Tdap IPV MMR Hepatitis B HPV

4.9. Travel

All travellers should be encouraged to consider vaccination requirements well in advance of overseas travel, including those who travel frequently for work or to visit family. It is recommended that they are up to date with age-appropriate Schedule vaccines (see Appendix 2 for advice on planning catch-up vaccination) and receive current information on overseas travel requirements (eg, COVID-19, typhoid, yellow fever, rabies, Japanese encephalitis vaccination).

Travellers can seek advice from a primary care practice with expertise in travel medicine or a specialist travel medicine clinic. Information is also available on the New Zealand Safe Travel and WHO websites.

Students entering New Zealand for study

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.

References

1. Global Advisory Committee on Vaccine Safety. 2014 Safety of immunization during pregnancy: A review of the evidence. Geneva. URL: https://www.who.int/vaccine_safety/publications/safety_pregnancy_nov2014.pdf?ua=1. (accessed 2021 June 11)
2. Shimabukuro TT, Kim SY, Myers TR, et al. Preliminary findings of mRNA COVID-19 vaccine safety in pregnant persons. New England Journal of Medicine, 2021. 384(24): p. 2273-2282.
3. Reef SE ,Plotkin S. 2018. Rubella Vaccines, in Plotkin's Vaccines (7th edition), Plotkin S, Orenstein W, Offit P, et al. (eds). Elsevier: Philadelphia, US.
4. Omer SB, Bednarczyk R, Madhi SA, et al. Benefits to mother and child of influenza vaccination during pregnancy. Human Vaccines & Immunotherapeutics, 2012. 8(1): p. 130-7.
5. Sakala IG, Honda-Okubo Y, Fung J, et al. Influenza immunization during pregnancy: Benefits for mother and infant. Human Vaccines & Immunotherapeutics, 2016. 12(12): p. 3065-3071.
6. Marshall H, McMillan M, Andrews RM, et al. Vaccines in pregnancy: The dual benefit for pregnant women and infants. Human Vaccines & Immunotherapeutics, 2016. 12(4): p. 848-56.
7. Shakib JH, Korgenski K, Presson AP, et al. Influenza in Infants Born to Women Vaccinated During Pregnancy. Pediatrics, 2016. 137(6): p. e20152360.
8. Global Advisory Committee on Vaccine Safety. 2014 Safety of immunization during pregnancy: A review of the evidence. World Health Organization; 2014 [updated 2014]; URL: https://www.who.int/vaccine_safety/publications/safety_pregnancy_nov2014.pdf?ua=1. (accessed 2 December 2019)
9. McHugh L, Marshall HS, Perrett KP, et al. The safety of influenza and pertussis vaccination in pregnancy in a cohort of australian mother-infant pairs, 2012-2015: The FluMum Study. Clinical Infectious Diseases, 2019. 68(3): p. 402-408.
10. McMillan M, Porritt K, Kralik D, et al. Influenza vaccination during pregnancy: a systematic review of fetal death, spontaneous abortion, and congenital malformation safety outcomes. Vaccine, 2015. 33(18): p. 2108-17.
11. Eberhardt CS, Blanchard-Rohner G, Lemaitre B, et al. Pertussis antibody transfer to preterm neonates after second- versus third-trimester maternal immunization. Clinical Infectious Diseases, 2017. 64(8): p. 1129-1132.
12. Schulzke S, Heininger U, Lucking-Famira M, et al. Apnoea and bradycardia in preterm infants following immunisation with pentavalent or hexavalent vaccines. European Journal of Pediatrics, 2005. 164(7): p. 432-5.
13. Vaz-de-Lima LRA, Sato HK, Fernandes EG, et al. Association between the timing of maternal vaccination and newborns' anti-pertussis toxin antibody levels. Vaccine, 2019. 37(36): p. 5474-5480.
14. Clifford V, Crawford NW, Royle J, et al. Recurrent apnoea post immunisation: Informing re-immunisation policy. Vaccine, 2011. 29(34): p. 5681-5687.
15. Chiu M, Bao C ,Sadarangani M. Dilemmas with rotavirus vaccine: The neonate and immunocompromised. Pediatric Infectious Disease Journal, 2019. 38(Suppl 6): p. S43-46.
16. Esposito S, Pugni L, Mosca F, et al. Rotarix® and RotaTeq® administration to preterm infants in the neonatal intensive care unit: Review of available evidence. Vaccine, 2018. 36(36): p. 5430-5434.
17. Sicard M, Bryant K, Muller ML, et al. Rotavirus vaccination in the neonatal intensive care units: where are we? A rapid review of recent evidence. Current Opinion in Pediatrics, 2020. 32(1): p. 167-191.
18. Eberhardt CS, Blanchard-Rohner G, Lemaitre B, et al. Maternal immunization earlier in pregnancy maximizes antibody transfer and expected infant seropositivity against pertussis. Clinical Infectious Diseases, 2016. 62(7): p. 829-836.
19. van den Berg JP, Westerbeek EA, van der Klis FR, et al. Transplacental transport of IgG antibodies to preterm infants: a review of the literature. Early Human Development, 2011. 87(2): p. 67-72.
20. Wilson E, Finucane K, Hamer M, et al. 2015 Immunisations and cardiac infants. Starship Child Health; 2015 [updated 2019]; URL: https://www.starship.org.nz/guidelines/immunisations-and-cardiac-infants. (accessed 28 April 2020)
21. Bakare N, Menschik D, Tiernan R, et al. Severe combined immunodeficiency (SCID) and rotavirus vaccination: reports to the Vaccine Adverse Events Reporting System (VAERS). Vaccine, 2010. 28(40): p. 6609-12.
22. Klinkenberg D, Blohm M, Hoehne M, et al. Risk of rotavirus vaccination for children with SCID. Pediatric Infectious Disease Journal, 2015. 34(1): p. 114-5.
23. Greenwood KP, Hafiz R, Ware RS, et al. A systematic review of human-to-human transmission of measles vaccine virus. Vaccine, 2016. 34(23): p. 2531-6.
24. Kamboj M ,Sepkowitz KA. Risk of transmission associated with live attenuated vaccines given to healthy persons caring for or residing with an immunocompromised patient. Infection Control and Hospital Epidemiology, 2007. 28(6): p. 702-7.
25. Marin M, Leung J ,Gershon AA. Transmission of Vaccine-Strain Varicella-Zoster Virus: A Systematic Review. Pediatrics, 2019. 144(3): p. e20191305.
26. American Academy of Pediatrics. 2018. Immunization and other considerations in immunocompromised children. in Red Book: 2018 report of the Committee on Infectious Diseases, Kimberlin D, Brady M, Jackson M, et al. (eds). Elk Grove Village, Illinois. p. 72-91.  URL: https://redbook.solutions.aap.org/redbook.aspx. (accessed 3 July 2020)
27. Huggard D, Doherty DG ,Molloy EJ. Immune Dysregulation in Children With Down Syndrome. Front Pediatr, 2020. 8: p. 73.
28. Ram G ,Chinen J. Infections and immunodeficiency in Down syndrome. Clinical and Experimental Immunology, 2011. 164(1): p. 9-16.
29. Duncan CJA, Randall RE ,Hambleton S. Genetic lesions of type I interferon signalling in human antiviral immunity. Trends in Genetics, 2021. 37(1): p. 46-58.
30. Pina LM, Bassily E, Machmer A, et al. Safety and immunogenicity of a quadrivalent meningococcal polysaccharide diphtheria toxoid conjugate vaccine in infants and toddlers: three multicenter phase III studies. Pediatric Infectious Disease Journal, 2012. 31(11): p. 1173-83.
31. American Academy of Pediatrics. 2021. Immunization and other considerations in immunocompromised children. in Red Book: 2021-2024 report of the Committee on Infectious Diseases (32nd Edition), Kimberlin D, Barnett E, Lynfield R, et al. (eds). Elk Grove Village, Illinois. p. 72-86.  URL: https://redbook.solutions.aap.org/redbook.aspx. (accessed 20 December 2022)
32. Bastard P, Hsiao K-C, Zhang Q, et al. A loss-of-function IFNAR1 allele in Polynesia underlies severe viral diseases in homozygotes. J. Exp. Med, 2022. 219(6).
33. Duncan CJA, Skouboe MK, Howarth S, et al. Life-threatening viral disease in a novel form of autosomal recessive IFNAR2 deficiency in the Arctic. Journal of Experimental Medicine, 2022. 219(6).
34. Meffre E ,Iwasaki A. Interferon deficiency can lead to severe COVID. Nature, 2020. 587(7834): p. 374-376.
35. Pairo-Castineira E, Clohisey S, Klaric L, et al. Genetic mechanisms of critical illness in COVID-19. Nature, 2021. 591(7848): p. 92-98.
36. Zhang Q, Bastard P, Liu Z, et al. Inborn errors of type I IFN immunity in patients with life-threatening COVID-19. Science, 2020. 370(6515): p. eabd4570.
37. Hernandez N, Bucciol G, Moens L, et al. Inherited IFNAR1 deficiency in otherwise healthy patients with adverse reaction to measles and yellow fever live vaccines. Journal of Experimental Medicine, 2019. 216(9): p. 2057-2070.
38. Danziger-Isakov L ,Posfay-Barbe KM. Optimal approach to immunization in pediatric solid organ transplantation. Pediatric Transplantation, 2012. 16(7): p. 680-683.
39. Suresh S, Upton J, Green M, et al. Live vaccines after pediatric solid organ transplant: Proceedings of a consensus meeting, 2018. Pediatric Transplantation, 2019. 23(7): p. e13571.
40. Gill N, Sirizzotti N, Johnson D, et al. Endogenous glucocorticoid response to single-dose dexamethasone for croup in children: A pharmacodynamic study. Pediatric Emergency Care, 2020. 36(1): p. 50-56.
41. Gedalia A ,Shetty AK. Chronic steroid and immunosuppressant therapy in children. Pediatrics in Review, 2004. 25(12): p. 425-34.
42. Mathias CB, McAleer JP ,Szollosi DE. 2020. Pharmacology of immunotherapeutic drugs (ed.), Cham: Springer. URL: https://link.springer.com/book/10.1007%2F978-3-030-19922-7 (accessed 3 July 2020)
43. Østensen M. Antirheumatic biologics in pregnant patients: a call for studies to address the knowledge gap. Expert Review of Clinical Immunology, 2018. 14(2): p. 95-97.
44. Berkhout A, Clark JE ,Wen SC-H. In utero exposure to biologic disease-modifying anti-rheumatic drugs and effects to the infant: infectious complications, vaccine response, and safety of live vaccine administration. Expert Review of Vaccines, 2019. 18(5): p. 495-504.
45. Zerbo O, Modaressi S, Goddard K, et al. Safety of Live-Attenuated Vaccines in Children Exposed to Biologic Response Modifiers in Utero. Pediatrics, 2022. 150(1).
46. Østensen M. Safety issues of biologics in pregnant patients with rheumatic diseases. Annals of the New York Academy of Sciences, 2014. 1317(1): p. 32-8.
47. Doganis D, Kafasi A, Dana H, et al. Immune response to influenza vaccination in children with cancer. Human Vaccines & Immunotherapeutics, 2018. 14(9): p. 2310-2317.
48. Vollaard A, Schreuder I, Slok-Raijmakers L, et al. Influenza vaccination in adult patients with solid tumours treated with chemotherapy. European Journal of Cancer, 2017. 76: p. 134-143.
49. Keam B, Kim MK, Choi Y, et al. Optimal timing of influenza vaccination during 3-week cytotoxic chemotherapy cycles. Cancer, 2017. 123(5): p. 841-848.
50. Pollyea DA, Brown JM ,Horning SJ. Utility of influenza vaccination for oncology patients. Journal of Clinical Oncology, 2010. 28(14): p. 2481-90.
51. Belka C, Ottinger H, Kreuzfelder E, et al. Impact of localized radiotherapy on blood immune cells counts and function in humans. Radiotherapy and Oncology, 1999. 50(2): p. 199-204.
52. Conrad A, Alcazer V, Valour F, et al. Vaccination post-allogeneic hematopoietic stem cell transplantation: What is feasible? Expert Review of Vaccines, 2018. 17(4): p. 299-309.
53. Cordonnier C, Einarsdottir S, Cesaro S, et al. Vaccination of haemopoietic stem cell transplant recipients: guidelines of the 2017 European Conference on Infections in Leukaemia (ECIL 7). The Lancet Infectious Diseases, 2019. 19(6): p. e200-212.
54. Chong PP ,Avery RK. A comprehensive review of immunization practices in solid organ transplant and hematopoietic stem cell transplant recipients. Clinical Therapeutics, 2017. 39(8): p. 1581-1598.
55. Danziger-Isakov L, Kumar D ,The A. S. T. I. D. Community of Practice. Vaccination of solid organ transplant candidates and recipients: Guidelines from the American society of transplantation infectious diseases community of practice. Clinical Transplantation, 2019. 33(9): p. e13563.
56. Di Sabatino A, Carsetti R ,Corazza GR. Post-splenectomy and hyposplenic states. The Lancet, 2011. 378(9785): p. 86-97.
57. Aberg JA, Gallant JE, Ghanem KG, et al. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clinical Infectious Diseases, 2014. 58(1): p. e1-34.
58. Mathew R, Mason D ,Kennedy JS. Vaccination issues in patients with chronic kidney disease. Expert Rev Vaccines, 2014. 13(2): p. 285-98.
59. Neuhaus TJ. Immunization in children with chronic renal failure: a practical approach. Pediatric Nephrology, 2004. 19(12): p. 1334-9.
60. Park SJ ,Shin JI. Complications of nephrotic syndrome. Korean Journal of Pediatrics, 2011. 54(8): p. 322-8.
61. Lin SY, Liu JH, Lin CL, et al. A comparison of herpes zoster incidence across the spectrum of chronic kidney disease, dialysis and transplantation. American Journal of Nephrology, 2012. 36(1): p. 27-33.
62. Ministry of Health. 2019. Guidelines for Tuberculosis Control in New Zealand, 2019 (ed.), Wellington: Ministry of Health. URL: https://www.health.govt.nz/publication/guidelines-tuberculosis-control-new-zealand-2019 (accessed 14 February 2020)
63. Institute of Environmental Science and Research (ESR). 2019 Tuberculosis in New Zealand Annual Report 2016. Porirua. URL: https://surv.esr.cri.nz/PDF_surveillance/AnnTBReports/TBannualreport2016.pdf. (accessed 3 July 2020)