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More advice on vaccines for immunocompromised patients

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For most people with immunocompromise, the Oxford University/AstraZeneca can be given at any time, and the main priority is to be vaccinated as early as possible, according to the Australian Technical Advisory Group on Immunisation (ATAGI).
 
‘Many immunocompromising conditions are associated with a higher risk of severe illness and complications from COVID-19 … [and] vaccination should be strongly encouraged,’ it states.
 
‘However, for some patients the optimal timing of vaccination requires special consideration.
 
‘Consultation with their treating specialist may be required. Providers can also refer relevant patients to the COVID-19 vaccination decision guide for people with immunocompromise’.
 
The new provider guide also states that while active disease is not a contraindication to vaccination, a short delay until the active disease is under control ‘may be advisable’ for people with severe illness, in order to avoid ‘incorrect attribution of vaccine-related adverse events’.
 
Likewise, deferring either immunosuppressive therapy or vaccination for a short period may be recommended in some circumstances, such as to allow for a better immune response to the vaccine or to reduce the risk of misattribution of adverse events.
 
However, in these instances, the timing of vaccination should be discussed with the patient’s treating specialist and in general, maintenance immunosuppression ‘should not be withheld or deferred for vaccination’ unless advised.
 
Vaccine providers should also discuss with the patient’s treating specialist the:

• optimal timing of vaccination in people taking immunosuppressive therapy (particularly B-cell depleting therapies such as rituximab), in order to maximise the immune response to vaccination
• best timing for people taking immune checkpoint inhibitors, so as to minimise the theoretical risk of immune-related adverse events being triggered by vaccination.

For people due to commence a new immunosuppressive treatment that is likely to impair the immune response to vaccination, the vaccine course should ideally be completed 2–4 weeks prior to initiation of the immunosuppression, and the typical interval can be reduced from 12 weeks to 28 days to accommodate this.
 
Other timing issues GPs need to be aware of, include:
 

• avoiding vaccination on the same day as a regular infusion (eg immunoglobulin replacement therapy, immunosuppressant infusion), and allow at least three days of spacing if possible
• avoiding vaccination during anticipated periods of neutropenia, or during periods of confirmed severe neutropenia (ANC < 0.5 x 109/L)
  • this is to avoid fever, which may result in additional investigations being required to rule out other differential diagnoses (such as sepsis)
• considering temporary deferral of vaccination or use additional precautions during periods of severe thrombocytopenia (eg platelet count < 50 x 109/L)
  • after vaccination, the injection site should not be rubbed, and firm pressure should be applied for 5–10 minutes
  • if a collection of blood develops, immobilise the area and apply an ice pack.

While people with immunocompromise were mostly excluded from COVID vaccine clinical trials and direct safety data is currently not available, the resource states that people with immunocompromise have already been given vaccines as a priority group in many countries.
 
‘So far no safety issues have been identified in people with immunocompromise,’ it states.
 
‘The safety profile of both vaccines is similar to other vaccines routinely used in people with immunocompromise.’
 
Aside from new information on people with immunocompromised, the Therapeutic Goods Administration (TGA) has also provided an update as to how long the Oxford University/AstraZeneca vaccine can sit in a drawn-up syringe for.
 
‘For practical reasons, if the contents of the vial are to be used within a short period of time, drawing up the content in multiple syringes at once may be considered,’ it states.
 
‘Vaccine in syringes may be kept for up to six hours when stored at room temperature [up to 30˚C].
 
‘However, ensure that the cumulative storage time at room temperature from the first vial puncture to last dose administration does not exceed six hours. After this time, the syringe must be discarded.’
 
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ATAGI COVID-19 immuncompromise vaccines

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