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Authors: Dr Diana Purvis, Paediatric Dermatologist, Starship Hospital, Auckland, New Zealand; Dr Gary Reynolds, Medical Advisor to Immunisation Advisory Centre, Auckland, New Zealand; 2012. Updated: Dr Jenny Chung, Dermatology Registrar, Middlemore Hospital, Auckland, New Zealand; Honorary Associate Professor Marius Rademaker, Waikato Clinical School, The University of Auckland, New Zealand; Honorary Associate Professor Paul Jarrett, Dermatologist, Middlemore Hospital and Department of Medicine, The University of Auckland, Auckland, New Zealand. Copy edited by Gus Mitchell. March 2021
The immune system is compromised when an immune response is not as efficient or efficacious as normal.
Dermatology patients may be immunocompromised due to:
Immunosuppression can result in serious bacterial, fungal, and viral infections which may not present with typical clinical features. All patients on immunomodulators should be warned of their increased infection risk and must particularly report exposure to chickenpox or measles. Immunocompromised patients who are unwell should be carefully evaluated and their infections actively treated.
Live viral and bacterial vaccines should not be administered to immunosuppressed patients due to the risk of developing a vaccine infection, and ideally these should be administered before starting immunomodulatory treatment.
An effective immune response can follow natural infection or vaccination/immunisation. Prior to starting any immunomodulatory therapy, the following should be determined:
The government-funded immunisation schedule is as follows.
Additional unfunded vaccinations that may be recommended prior to travel in endemic areas may include hepatitis A, cholera, typhoid, cholera, rabies, and BCG.
COVID-19 vaccination programs are being rolled out around the world.
Check varicella, measles, hepatitis A/B/C, HIV, and Chagas serology. There are currently no vaccines for Chagas disease, hepatitis C, or HIV. Treatment for tuberculosis, Chagas disease, hepatitis C, and HIV should be started if required prior to initiating immunomodulating therapies.
At least one month prior to starting immunomodulating therapies, the following immunisations should be given to minimise the risk of preventable infections:
Passive antibody protection is required for significantly immunosuppressed patients following exposure to varicella or measles, whether or not they have detectable antiviral IgG antibodies.
Varicella is infectious from two days before the rash appears until the blisters have crusted over. The incubation period is 7–21 days following exposure. ‘Significant exposure’ is defined as 15 minutes or more of close contact/play with an individual with chickenpox or shingles.
Passive protection for an immunosuppressed patient should be provided with varicella-zoster immune globulin (VZIG) within 96 hours (ideally 72 hours) of contact. This is not considered necessary for those on low dose immunosuppression with detectable specific IgG antibodies.
Measles is highly contagious and is infectious from 5 days before the rash appears until 4 days after the onset of the rash. The incubation period is 10–14 days after exposure. ‘Significant contact’ is defined as 15 minutes or more of close contact/play with an infectious individual who has measles confirmed on serology.
Passive protection is required for an immunosuppressed patient regardless of antibody status, using normal immune globulin (NIG) within 6 days (ideally within 72 hours) of contact. MMR vaccination should be given within 72 hours of significant measles contact for non-immunosuppressed individuals.
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