Vaccination for people who are immunocompromised
People who are immunocompromised have an increased risk of severe illness or death from many vaccine-preventable diseases. Some vaccines are contraindicated in people who are immunocompromised. In addition these people may need extra doses of some vaccines to optimise protection.
Recently added
This page was added on 09 June 2018.
Updates made
This page was updated on 02 May 2025. View history of updates
Introduction and general principles
People who are immunocompromised have an increased risk of severe illness or death from many vaccine-preventable diseases.
A person can be immunocompromised as a result of:
- a congenital condition
- a medical condition, or
- following immunosuppressive medical treatment
The vaccination history of people who are immunocompromised needs to be assessed carefully and a plan made for future vaccination.
Live vaccines may be contraindicated in immunocompromised people due to the risk of adverse events or vaccine-related disease. Live vaccines can, in some situations, cause severe or fatal infections in immunosuppressed individuals due to extensive replication of the vaccine strain.
If there is uncertainty about how severely a person is immunocompromised or whether it is safe for them to receive a vaccine, do not vaccinate them. Seek further advice from their treating physician or an immunisation specialist.
Non-live vaccines are made from viruses or bacteria that have been killed or inactivated so they cannot replicate. Those vaccines can be safely administered to immunosuppressed individuals, although they may elicit a lower response than in immunocompetent individuals. Extra doses of non-live vaccines (such as pneumococcal and COVID-19 vaccines) may be needed to optimise protection against these specific diseases.
See Infographic. Vaccination for people who are immunocompromised.
An individual’s susceptibility to infections and the ability to mount an immune response to vaccines can vary according to the degree and type of immune suppression. It may also change over time or be influenced by immunomodulating medications or changes in the underlying disease.
This means that vaccine administration and schedules need to be individualised for each person who is immunocompromised. However, many shared principles apply: the overarching aim is to maximise the benefits of vaccine protection, while minimising any potential risks of adverse events.
Principles and recommendations for people with different types of immunocompromise
For more details about principles and recommendations for people with different types of immunocompromise, see:
- Inborn errors of immunity, including primary immunodeficiency
- Secondary (acquired) immunodeficiency due to medical conditions
- Secondary (acquired) immunodeficiency due to medical therapies
- People with asplenia and hyposplenia
- Infants exposed to immunosuppressive therapy in utero or through breastmilk
- Close contacts of people who are immunocompromised
- Travellers who are immunocompromised
For more details about the immunosuppressive potential of various medications and medical conditions, see:
- Table. Types of medical conditions and immunosuppressive therapy and associated levels of immunocompromise
- Table. Immunosuppressive potential of cancer and organ rejection therapies
- Table. Immunosuppressive potential of conventional (non-biological) immunosuppressive therapies
- Table. Immunosuppressive potential of small molecule targeted therapies
- Table. Immunosuppressive potential of biological therapies
- Table. Immunosuppressive potential of corticosteroids
- Table. Immunosuppressive potential of certain medical conditions
Definitions
This Handbook uses the following definitions:
- Immunocompetence — a normally functioning immune system
- Immunocompromise — a broad term referring to a weakened (deficient) immune system, which may be restricted to one part, or impact many parts, of the immune system. Immunocompromise may occur due to a primary immunodeficiency (inborn error of immunity) or secondary immunodeficiency (caused by medical conditions or exposure to certain medications).
- Immunosuppression — a reduced ability to respond to infections due to a suppressed immune system, usually secondary to medications
- Immunomodulation — alteration in immune system functioning, usually due to the use of medications that may either reduce or enhance the immune response (such as chemotherapy or immunotherapy)
The level of immunocompromise will vary for each individual, and is determined by many factors, including underlying disease, exposure to medications and other individual risk factors. However, general principles can be applied when considering the degree of immunocompromise that may affect a person’s ability to respond to vaccination or their susceptibility to a vaccine-preventable disease. Here we focus on an overall classification based on underlying medical conditions and therapies:
- Mild immunocompromise — may increase the risk of infection resulting in a higher likelihood of contracting a vaccine-preventable disease, or may result in a less robust response to vaccination. Generally, live vaccines can be given to people who are mildly immunocompromised.
- Moderate immunocompromise — may result in a higher risk of infection and potentially severe outcomes from vaccine-preventable diseases, and often results in a reduced response to vaccination. Generally, live vaccines are contraindicated in people who are moderately immunocompromised because of the potential safety concerns (see Safety considerations: live vaccines).
- Severe immunocompromise — may result in a significantly increased risk of severe vaccine-preventable disease and poor response to vaccination. Live vaccines are contraindicated in people who are severely immunocompromised because of the potential safety concerns (see Safety considerations: live vaccines).
| Type of immunosuppression | Example conditions (not an exhaustive list) | Specific therapies that may affect level of immunocompromise | Overall level of immunocompromise |
|---|---|---|---|
| Inborn errors of immunity, including primary immunodeficiency |
Antibody (B-cell) immunodeficiencies: less severe
|
No routine immunosuppressive therapies prescribed | Moderate |
|
Antibody (B-cell) immunodeficiencies: severe
|
Some patients may proceed to stem cell transplant, which will increase this level of immunosuppression | Severe | |
|
T-cell or combined (T- and B-cell) immunodeficiencies: less severe
|
Some patients may proceed to stem cell transplant, which will increase this level of immunosuppression | Moderate | |
|
T-cell or combined (T- and B-cell) immunodeficiencies: severe
|
Some patients may proceed to stem cell transplant, which will increase this level of immunosuppression | Severe | |
|
Phagocytic and neutrophil disorders
|
No routine immunosuppressive therapies prescribed, but antibiotic prophylaxis may be indicated | Moderate | |
|
Defects of innate immunity
|
No routine immunosuppressive therapies prescribed, but antibiotic prophylaxis may be indicated |
Moderate Susceptibilities to different pathogens depends on specific types of innate immune defects. See Defects of innate immunity: recommendations for vaccination |
|
|
Complement deficiencies (primary)
|
No routine immunosuppressive therapies prescribed, but antibiotic prophylaxis may be indicated |
Mild However, specific risk of infection with encapsulated bacteria (eg Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis) |
|
| Complement deficiencies (secondary) Secondary complement deficiencies due to prescribing complement inhibitors | May be treated with complement inhibitors (eg eculizumab, ravulizumab) |
Mild However, specific risk of infection with encapsulated bacteria (eg Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis) |
|
| Common autoimmune and inflammatory conditions |
Rheumatological
Dermatological
Gastrointestinal
Neurological
|
No active treatment and disease in remission | Mild |
|
Treated with selected or low-dose conventional immunosuppressive therapies:
|
Generally mild to moderate, depending on prescribed dosage and mechanism of action. See Table. Recommended timing of live vaccine administration for people receiving immunosuppressive therapies and Table. Recommended timing of live vaccine administration for people receiving corticosteroids for more detail. | ||
|
Treated with selected or high-dose immunosuppressive therapies:
|
Severe during or <3 months after therapy completion | ||
| Moderate: >3 months after therapy completion | |||
| Treated with high-dose corticosteroids: >20 mg/day (infants and children <10kg: >2 mg/kg/day) for >14 days | Severe during or <4 weeks after therapy completion | ||
| Moderate: >4 weeks after therapy completion | |||
| Treated with B-cell depleting biological therapies (eg rituximab) | Severe: during or <6 months after therapy completion | ||
| Moderate: >6 months after therapy completion | |||
| Treated with small molecule targeted therapies JAK inhibitors (eg tofacitinib) |
Mild However, specific risk of infection with certain viruses (eg herpes zoster reactivation) |
||
| Oncological diagnoses | Haematological | Chronic malignancies not on active treatment and in cancer remission | Moderate |
|
Treated with small molecule targeted therapies
|
Moderate | ||
| Treated with immunomodulatory drugs (eg thalidomide, lenalidomide, pomalidomide) | Severe: during relapsed/refractory stage or multidrug regimens | ||
| Moderate: during maintenance stage | |||
| Treated with B-cell and T-cell targeting biological therapies (eg rituximab, ofatumumab, alemtuzumab) or bispecific agents | Severe: first 6 months after therapy completion | ||
| Moderate: >6 months after therapy completion | |||
| Treated with stem cell transplant or cellular therapies (eg HSCT, CAR-T therapy) | Severe: first 24 months after therapy completion | ||
| Moderate: >24 months after therapy completion | |||
| Solid tumours | Completed active therapy and in cancer remission | Mild | |
| Treated with hormonal therapy | Mild | ||
| Treated with immune checkpoint inhibitors | Mild | ||
|
Treated with small molecule targeted therapies
|
Mild | ||
| Treated with radiotherapy | Generally mild, but may be moderate or severe depending on site and extent of radiotherapy. | ||
| Treated with conventional chemotherapy | Severe: during or <3 months after therapy completion | ||
| Moderate: >3 months after therapy completion | |||
| Solid organ transplant | Before solid organ transplant |
Multiple immunosuppressants may be prescribed to treat the underlying organ failure, for details, see:
|
Moderate |
| After solid organ transplant | Anti-rejection agents (such as mycophenolate, mTOR inhibitors, calcineurin inhibitors, corticosteroids) may be prescribed with reduced dosing over time | Severe: first 12 months after transplant | |
| Moderate: >12 months after transplant | |||
| Asplenia or hyposplenia | Anatomical or functional asplenia or hyposplenia (eg congenital asplenia, sickle cell anaemia, splenectomy) | No routine immunosuppressive therapies prescribed, but antibiotic prophylaxis may be indicated | Moderate, mainly due to risk of infection with specific bacterial pathogens. |
| HIV infection |
|
No routine immunosuppressive therapies prescribed, but highly active combination antiretroviral therapy prescribed (with or without agents to prevent opportunistic infections) | Mild |
|
No routine immunosuppressive therapies prescribed, but highly active combination antiretroviral therapy prescribed (with or without agents to prevent opportunistic infections) | Moderate | |
|
No routine immunosuppressive therapies prescribed, but highly active combination antiretroviral therapy prescribed (with or without agents to prevent opportunistic infections) | Severe | |
|
Acronyms used:
|
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Safety considerations: non-live vaccines
Non-live vaccines are generally safe to administer to people who are immunocompromised, as the antigens in the vaccine do not pose an infection risk. However, these vaccines are often less immunogenic in people who are immunocompromised, and extra doses may be needed.
Safety considerations: live vaccines
The use of live vaccines in people who are severely immunocompromised can cause serious adverse events. These can include uninhibited replication of the virus or bacteria, causing an overwhelming infection.
Before giving a live vaccine to a person who is immunocompromised, consider consulting with a specialist who has expertise in immunodeficiency or infectious diseases. People who are mildly or moderately immunocompromised should also be assessed by a specialist, as the benefits of live vaccines may outweigh perceived risks.
The timing of vaccination should be selected to optimise the immune response, where possible. This may mean:
- vaccinating before any planned immunosuppression, or
- deferring vaccination if immunocompromise is expected to be transient
- deferring vaccination until after corrective therapy such as stem cell or thymic transplant if this is expected to occur in early childhood.
Consider vaccinating close contacts with recommended vaccines to optimise protection for the person who is immunocompromised, particularly if live vaccines are contraindicated for the person who is immunocompromised. See Vaccination for close contacts of people who are immunocompromised.
Inadvertent administration of live vaccines to people who are immunocompromised
If a person who is immunocompromised is inadvertently given a live vaccine, they need prompt review to consider the degree of immunocompromise and the likelihood of experiencing an adverse event.
If a person is considered moderately to severely immunocompromised, urgent management may be needed. This may include:
- passive immunoglobulin, and/or
- antiviral therapy, and/or
- antibacterial therapy
Seek advice from a specialist immunisation service or local infectious disease specialist.
Notify your relevant state or territory health authority and report as an Adverse Event Following Immunisation.
Page history
An updated immunocompromised chapter offers comprehensive information and recommendations for people who are immunocompromised. The chapter provides clear immunocompromise definitions and categorises the level of immunocompromise across various types of conditions, including inborn errors of immunity, secondary immunodeficiencies due to medical conditions or therapies, asplenia, infants exposed to immunosuppression in utero, immunocompromised close contacts, and immunocompromised travellers. This chapter will serve as a primary reference for detailed information and vaccination guidance tailored to each immunocompromising condition, in alignment with specific disease chapters.
Removal of Trumenba information from Table. Recommendations for revaccination after haematopoietic stem cell transplant in children and adults. Change the mpox vaccine from the list of live vaccines to the list of inactivated vaccines.
Updates to include new recommendations for RSV vaccines, Abrysvo and Arexvy, in people who are immunocompromised, people with cancer, solid organ transplant recipients, Haematopoietic stem cell transplant recipients, people with HIV and people with functional or anatomical asplenia.
Updates to reflect availability of the live-attenuated, replicant-deficient vaccine mpox vaccine, JYNNEOS. Updates to include recommendations for use in immunocompromised people. Updates throughout the chapter to reflect the availability of Prevenar 20 (20vPCV) in infants and children from 6 weeks of age. Updates to reflect rare risk of GBS following Shingrix.
Updates throughout the page to reflect the availability of Vaxchora oral cholera vaccine and Verorab rabies vaccine.
Update to clinical guidance regarding Recombinant Zoster vaccine (Shingrix) in Table. Recommended vaccines for people before and after a solid organ transplant and Table. Recommendations for revaccination after haematopoietic stem cell transplant in children and adults.
Minor updates to clinical guidance throughout the chapter to reflect amended age indications for the pneumococcal conjugate vaccine Vaxneuvance and the addition of COVID-19 vaccine.
Updates to clinical guidance in multiple sections to reflect the addition of a 20-valent pneumococcal conjugate vaccine.
Update to guidance regarding HPV vaccination for People who have completed cancer therapy, Solid Organ transplant recipients and Haematopoietic stem cell transplant recipients.
Updates to clinical guidance throughout the chapter to include 15-valent pneumococcal conjugate vaccine (15vPCV) where appropriate.
- Update to guidance regarding MenB vaccination for People who have completed cancer therapy and Haematopoietic stem cell transplant recipients.
- Updates to include guidance on recombinant zoster vaccine (Shingrix).
Changes to pneumococcal vaccine recommendations for people who are immunocompromised.
Editorial changes to 'Table. Recommended timing of live vaccine doses in adults and children taking corticosteroids' in the ‘Use of live vaccines in people who are immunocompromised' section, to correct prednisone-equivalent doses for children and adolescents aged <16 years who weigh >10 kg.
Guidance on assessing the level of immunocompromise in children and adults with HIV updated.
Guidance on vaccination of infants born to mothers who received bDMARDs during pregnancy updated.
An updated immunocompromised chapter offers comprehensive information and recommendations for people who are immunocompromised. The chapter provides clear immunocompromise definitions and categorises the level of immunocompromise across various types of conditions, including inborn errors of immunity, secondary immunodeficiencies due to medical conditions or therapies, asplenia, infants exposed to immunosuppression in utero, immunocompromised close contacts, and immunocompromised travellers. This chapter will serve as a primary reference for detailed information and vaccination guidance tailored to each immunocompromising condition, in alignment with specific disease chapters.
Removal of Trumenba information from Table. Recommendations for revaccination after haematopoietic stem cell transplant in children and adults. Change the mpox vaccine from the list of live vaccines to the list of inactivated vaccines.
Updates to include new recommendations for RSV vaccines, Abrysvo and Arexvy, in people who are immunocompromised, people with cancer, solid organ transplant recipients, Haematopoietic stem cell transplant recipients, people with HIV and people with functional or anatomical asplenia.
Updates to reflect availability of the live-attenuated, replicant-deficient vaccine mpox vaccine, JYNNEOS. Updates to include recommendations for use in immunocompromised people. Updates throughout the chapter to reflect the availability of Prevenar 20 (20vPCV) in infants and children from 6 weeks of age. Updates to reflect rare risk of GBS following Shingrix.
Updates throughout the page to reflect the availability of Vaxchora oral cholera vaccine and Verorab rabies vaccine.
Update to clinical guidance regarding Recombinant Zoster vaccine (Shingrix) in Table. Recommended vaccines for people before and after a solid organ transplant and Table. Recommendations for revaccination after haematopoietic stem cell transplant in children and adults.
Minor updates to clinical guidance throughout the chapter to reflect amended age indications for the pneumococcal conjugate vaccine Vaxneuvance and the addition of COVID-19 vaccine.
Updates to clinical guidance in multiple sections to reflect the addition of a 20-valent pneumococcal conjugate vaccine.
Update to guidance regarding HPV vaccination for People who have completed cancer therapy, Solid Organ transplant recipients and Haematopoietic stem cell transplant recipients.
Updates to clinical guidance throughout the chapter to include 15-valent pneumococcal conjugate vaccine (15vPCV) where appropriate.
- Update to guidance regarding MenB vaccination for People who have completed cancer therapy and Haematopoietic stem cell transplant recipients.
- Updates to include guidance on recombinant zoster vaccine (Shingrix).
Changes to pneumococcal vaccine recommendations for people who are immunocompromised.
Editorial changes to 'Table. Recommended timing of live vaccine doses in adults and children taking corticosteroids' in the ‘Use of live vaccines in people who are immunocompromised' section, to correct prednisone-equivalent doses for children and adolescents aged <16 years who weigh >10 kg.
Guidance on assessing the level of immunocompromise in children and adults with HIV updated.
Guidance on vaccination of infants born to mothers who received bDMARDs during pregnancy updated.