Immunocompromised Schoolchildren - Risk Group Information Statement (RGIS)

Vaccines: What About Immunocompromised Schoolchildren?

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1. WHAT DOES IT MEAN TO BE IMMUNOCOMPROMISED?

Immunocompromised children have weakened immune systems that prevent them from optimally fighting infections on their own. Consequently, they may be at increased risk of complications from infectious diseases and require additional precautions and treatments.

2. CAN IMMUNOCOMPROMISED CHILDREN ATTEND SCHOOL?

The Immune Deficiency Foundation states, “Years ago, a diagnosis of a PI [primary immune deficiency] meant extremely compromised lives… Today, with early diagnosis and appropriate therapies, many patients diagnosed with a PI can live healthy, productive lives.” Modern treatments have reduced the risk of many immunocompromised children so that they are able to attend school.1

✓Children who are not severely immunocompromised can attend school with the approval of their doctor.

3. CAN IMMUNOCOMPROMISED SCHOOLCHILDREN BE VACCINATED?

Immunocompromised schoolchildren have the option to receive all the vaccines licensed for children in the United States, except for the live virus vaccines (such as vaccines targeting measles, mumps, rubella, or varicella infections).2 Although vaccination often results in protective levels of antibodies in immunocompromised children,3-7 clinical vaccine safety trials typically exclude immunocompromised subjects.8 In addition, vaccines have not been evaluated for their potential to cause cancer, genetic mutations or impaired fertility in the general or immunocompromised population.9 Due to these limitations, it is not known whether the benefit of vaccinating an immunocompromised child outweighs the risk of vaccine injury to that child.

In addition, vaccines have not been evaluated for their potential to cause cancer, genetic mutations or impaired fertility in the general or immunocompromised population.9 Due to these limitations, it is not known whether the benefit of vaccinating an immunocompromised child outweighs the risk of vaccine injury to that child.

4. DOES THE VACCINATION STATUS OF OTHER SCHOOLCHILDREN POSE A SIGNIFICANT RISK TO IMMUNOCOMPROMISED SCHOOLCHILDREN?

The vaccination status of other schoolchildren does not pose a significant risk to immunocompromised schoolchildren for the following reasons (Table 1):

  • Some vaccines cannot prevent the spread of the bacteria or viruses they target.
  • Immune globulin (plasma containing antibodies) is available for immunocompromised children exposed to certain infectious diseases.
  • Some infectious diseases rarely cause complications in immunocompromised schoolchildren.
  • Not all infectious diseases are contagious.
  • Some infectious diseases are not spread in schools

Immunocompromised schoolchildren are not put at significant risk by the vaccination status of other schoolchildren.

Table 1: Why the Vaccination Status of Other Schoolchildren Is Not a Significant Risk to Immunocompromised Schoolchildren

Some vaccines cannot  prevent the spread of  the bacteria or viruses  they target.

Children vaccinated with the diphtheria, tetanus, and pertussis (whooping cough) vaccine (DTaP) or the inactivated polio vaccine (IPV) can still be infected with diphtheria-causing bacteria, pertussis bacteria, or poliovirus and spread them to others, even with mild or no symptoms of their own.10-13 The influenza vaccines (TIV and LAIV) have not been observed to significantly reduce the spread of influenza.14,15 About half of schoolchildren vaccinated with the measles, mumps, and rubella (MMR) vaccine can still be infected with measles virus and spread it to others, even with mild or no symptoms of their own.16-19 Several studies of the COVID-19 vaccine suggest that the vaccine has had no measurable impact on preventing transmission.20-22

Immune globulin (plasma containing antibodies) is available for immunocompromised children exposed to certain infectious diseases.

Immune globulin (IG) is available for the prevention of severe symptoms in immunocompromised children exposed to measles or rubella (IG does not provide protection for fetuses of expectant mothers infected with rubella).23,24 Varicella-zoster immune globulin (VIG) is available for the prevention of severe symptoms in immunocompromised children exposed to varicella (chickenpox).25 Hepatitis B immune globulin (HBIG) and tetanus immune globulin (TIG) are also available for immunocompromised children.2 And, monoclonal antibodies are available for the treatment of COVID-19 in certain immunocompromised adolescents.26

Some infectious diseases rarely cause complications in immunocompromised schoolchildren.

Fatal cases of mumps are very rare in schoolchildren (1 in 100,000 mumps cases is fatal),27,28 and immunocompromised children have been observed to recover just as well from mumps as the general population.29 Severe cases of pertussis or rubella rarely occur in schoolchildren, and being immunocompromised has not been observed to be a significant risk factor for complications of pertussis or rubella in schoolchildren.30,31 Severe cases of COVID-19 also rarely occur in schoolchildren (between 2020 and 2022, about 1 in 70,000 children age 17 or younger died of COVID-19).32

Not all infectious diseases are contagious.

Tetanus is not a communicable disease; that is, it cannot spread from person to person.33

Some infectious diseases are not spread in schools.

Hepatitis B is not spread by kissing, hugging, holding hands, coughing, sneezing, or sharing eating utensils,34 and the main routes of hepatitis B transmission (sexual contact, injection drug use, or being born to an infected mother)35 do not occur in school. Nearly all cases of Haemophilus influenzae type b (Hib) occur among children younger than 5 years of age; therefore, nearly all Hib transmission does not occur in school.36 Human papillomavirus (HPV) is sexually transmitted and is therefore not spread in school.37 

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References

  1. Blaese RM, Ludwig M, Buckley R, Seymour JW, Dodds M. Immune Deficiency Foundation school guide for students with primary immunodeficiency diseases. 3rd ed. Towson (MD): Immune Deficiency Foundation; 2014. 6. https://physiciansforinformedconsent.org/immune-deficiency-foundation-school-guide-for-students-with-primary-immunodeficiency-diseases-3rd-ed/.
  2. Centers for Disease Control and Prevention. Recommendations of the Advisory Committee on Immunization Practices (ACIP): use of vaccines and immune globulins in persons with altered immunocompetence. MMWR. 1993 Apr;42(No. RR-04). https://www.cdc.gov/mmwr/preview/mmwrhtml/00023141.htm.
  3. Ercan TE, Soycan LY, Apak H, Celkan T, Ozkan A, Akdenizli E, Kasapçopur O, Yildiz I. Antibody titers and immune response to diphtheria-tetanus-pertussis and measles-mumps-rubella vaccination in children treated for acute lymphoblastic leukemia. J Pediatr Hematol Oncol. 2005 May;27(5):273-7. https://www.ncbi.nlm.nih.gov/pubmed/15891564.
  4. Feldman S, Gigliotti F, Shenep JL, Roberson PK, Lott L. Risk of Haemophilus influenzae type b disease in children with cancer and response of immunocompromised leukemic children to a conjugate vaccine. J Infect Dis. 1990 May;161(5):926-31. https://www.ncbi.nlm.nih.gov/pubmed/2324541.
  5. Hodges GR, Davis JW, Lewis HD Jr, Siegel CD, Chin TD, Clark GM, Noble GR. Response to influenza A vaccine among high-risk patients. South Med J. 1979 Jan;72(1):29-32. https://www.ncbi.nlm.nih.gov/pubmed/366766.
  6. Moss WJ, Clements CJ, Halsey NA. Immunization of children at risk of infection with human immunodeficiency virus. Bull of the World Health Organ. 2003;81(1):62,64. https://www.ncbi.nlm.nih.gov/pubmed/12640478.
  7. Barbi M, Bardare M, Luraschi C, Zehender G, Clerici Schoeller M, Ferraris G. Antibody response to inactivated polio vaccine (E-IPV) in children born to HIV positive mothers. Eur J Epidemiol. 1992 Mar;8(2):211-6. https://www.ncbi.nlm.nih.gov/pubmed/1644138.
  8. Centers for Disease Control and Prevention. Manual for the surveillance of vaccine-preventable diseases. 5th ed. Miller ER, Haber P, Hibbs B, Broder K. Chapter 21: surveillance for adverse events following immunization using the Vaccine Adverse Event Reporting System (VAERS). Atlanta: Centers for Disease Control and Prevention; 2011. 1,2. https://physiciansforinformedconsent.org/cdc-manual-for-the-surveillance-of-vaccine-preventable-diseases-5th-ed-chpt21-surv-adverse-events-2011/.
  9. U.S. Food and Drug Administration. Silver Spring (MD): U.S. Food and Drug Administration. Vaccines licensed for use in the United States; [updated 2018 Feb 14; cited 2018 Feb 27]. https://www.fda.gov/vaccines-blood-biologics/vaccines/vaccines-licensed-use-united-states.
  10. Miller LW, Older JJ, Drake J, Zimmerman S. Diphtheria immunization. Effect upon carriers and the control of outbreaks. Am J Dis Child. 1972 Mar;123(3):197-9. https://www.ncbi.nlm.nih.gov/pubmed/5026197.
  11. Warfel JM, Zimmerman LI, Merkel TJ. Acellular pertussis vaccines protect against disease but fail to prevent infection and transmission in a nonhuman primate model. Proc Natl Acad Sci USA. 2014 Jan 14;111(2):787-92. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3896208.
  12. Cuba IPV Study Collaborative Group. Randomized, placebo-controlled trial of inactivated poliovirus vaccine in Cuba. N Engl J of Med. 2007 Apr 12;356(15):1536-44. http://www.nejm.org/doi/full/10.1056/NEJMoa054960?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed.
  13. Centers for Disease Control and Prevention. Washington, D.C.: U.S. Department of Health and Human Services. U.S. National Authority for Containment of Poliovirus: interim guidance for potentially infectious materials; [cited 2024 Jul 13]. https://www.cdc.gov/orr/polioviruscontainment/00_docs/10.2022_cpr-issue-brief_nac-lab-testing-for-poliovirus_508_1.pdf.
  14. Thomas RE, Jefferson T, Lasserson TJ. Influenza vaccination for healthcare workers who care for people aged 60 or older living in long-term care institutions. Cochrane Database Syst Rev. 2016 Jun 2;(6) CD005187:2. https://www.ncbi.nlm.nih.gov/pubmed/27251461.
  15. Ohmit SE, Petrie JG, Malosh RE, Cowling BJ, Thompson MG, Shay DK, Monto AS. Influenza vaccine effectiveness in the community and the household. Clin Infect Dis. 2013 May;56(10):1363. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3693492.
  16. LeBaron CW, Beeler J, Sullivan BJ, Forghani B, Bi D, Beck C, Audet S, Gargiullo P. Persistence of measles antibodies after 2 doses of measles vaccine in a postelimination environment. Arch Pediatr Adolesc Med. 2007 Mar;161(3):294-301. https://www.ncbi.nlm.nih.gov/pubmed/17339511; children with measles antibody levels less than 900 mIU/mL are susceptible to subclinical infection with measles virus but not to clinical infection. About 35% of vaccinated children 7 years of age have a measles antibody level less than 900 mIU/mL. This level steadily declines through childhood, resulting in about 60% of children 15 years of age with a measles antibody level less than 900 mIU/mL. Consequently, about half of schoolchildren are susceptible to infection with measles virus.
  17. Pedersen IR, Mordhorst CH, Glikmann G, von Magnus H. Subclinical measles infection in vaccinated seropositive individuals in arctic Greenland. Vaccine. 1989 Aug;7(4):345-8. https://www.ncbi.nlm.nih.gov/pubmed/2815970.
  18. Chen RT, Markowitz LE, Albrecht P, Stewart JA, Mofenson LM, Preblud SR, Orenstein WA. Measles antibody: reevaluation of protective titers. J Infect Dis. 1990 Nov;162(5):1036-42. https://www.ncbi.nlm.nih.gov/pubmed/2230231.
  19. Mizumoto K, Kobayashi T, Chowell G. Transmission potential of modified measles during an outbreak, Japan, March–May 2018. Euro Surveill. 2018 Jun 14;23(24):1800239. https://www.ncbi.nlm.nih.gov/pubmed/29921344.

  20. Shitrit P, Zuckerman NS, Mor O, Gottesman BS, Chowers M. Nosocomial outbreak caused by the SARS-CoV-2 Delta variant in a highly vaccinated population, Israel, July 2021. Euro Surveill. 2021 Sep;26(39). https://pubmed.ncbi.nlm.nih.gov/34596015.

  21. Brown CM, Vostok J, Johnson H, Burns M, Gharpure R, Sami S, Sabo RT, Hall N, Foreman A, Schubert PL, Gallagher GR, Fink T, Madoff LC, Gabriel SB, MacInnis B, Park DJ, Siddle KJ, Harik V, Arvidson D, Brock-Fisher T, Dunn M, Kearns A, Laney AS. Outbreak of SARS-CoV-2 infections, including COVID-19 vaccine breakthrough infections, associated with large public gatherings—Barnstable County, Massachusetts, July 2021. MMWR Morb Mortal Wkly Rep. 2021 Aug 6;70(31):1059-62. https://www.cdc.gov/mmwr/volumes/70/wr/mm7031e2.htm?s_cid=mm7031e2_w.

  22. Subramanian SV, Kumar A. Increases in COVID-19 are unrelated to levels of vaccination across 68 countries and 2947 counties in the United States. Eur J Epidemiol. 2021 Sep 30:1-4. https://pubmed.ncbi.nlm.nih.gov/34591202.

  23. McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS; Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2013 Jun;62(RR-04):17,24. https://www.ncbi.nlm.nih.gov/pubmed/23760231.

  24. Young MK, Cripps AW, Nimmo GR, van Driel ML. Post-exposure passive immunisation for preventing rubella and congenital rubella syndrome. Cochrane Database Syst Rev. 2015 Sep 9;(9)CD010586:3. https://www.ncbi.nlm.nih.gov/pubmed/26350479.

  25. Centers for Disease Control and Prevention. Varicella-zoster immune globulin for the prevention of chickenpox: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR. 1984 Feb;33(7):84-90,95-100. https://www.cdc.gov/mmwr/preview/mmwrhtml/00022690.htm.
  26. U.S. Food and Drug Administration. Silver Spring (MD): U.S. Food and Drug Administration. FDA news release — FDA roundup: March 22, 2024; [cited 2024 Aug 30]. https://www.fda.gov/news-events/press-announcements/fda-roundup-march-22-2024.
  27. Wagenvoort JH, Harmsen M, Boutahar-Trouw BJ, Kraaijeveld CA, Winkler KC. Epidemiology of mumps in the Netherlands. J Hyg (Lond). 1980 Dec;85(3):313-26. https://www.ncbi.nlm.nih.gov/pubmed/7462586; before the mumps vaccine was licensed in 1967, nearly everyone contracted mumps in childhood. In 1966, there were 43 mumps deaths28 out of 4 million cases (the average size of a birth cohort in the 1960s): about 1 mumps death per 100,000 mumps cases.
  28. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 13th ed. Hamborsky J, Kroger A, Wolfe S, editors. Washington, D.C.: Public Health Foundation; 2015. Appendix E3. https://physiciansforinformedconsent.org/cdc-pink-book-13th-edition-and-appendix-e-2015-combo/.
  29. de Boer AW, de Vaan GA. Mild course of mumps in patients with acute lymphoblastic leukaemia. Eur J Pediatr. 1989 Jun;148(7):618-9. https://pubmed.ncbi.nlm.nih.gov/2744034.
  30. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 13th ed. Hamborsky J, Kroger A, Wolfe S, editors. Washington, D.C.: Public Health Foundation; 2015. 262,263,265. https://physiciansforinformedconsent.org/cdc-pink-book-13th-edition-and-appendix-e-2015-combo/.
  31. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 13th ed. Hamborsky J, Kroger A, Wolfe S, editors. Washington, D.C.: Public Health Foundation; 2015. 325,326. https://physiciansforinformedconsent.org/cdc-pink-book-13th-edition-and-appendix-e-2015-combo/.
  32. Centers for Disease Control and Prevention. Washington, D.C.: U.S. Department of Health and Human Services. CDC wonder: about underlying cause of death, 2018-2022, single race; [cited 2024 Aug 8]. https://wonder.cdc.gov/ucd-icd10-expanded.html. Query for COVID-19 deaths of age 17 or younger, 2020-2022.
  33. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 13th ed. Hamborsky J, Kroger A, Wolfe S, editors. Washington, D.C.: Public Health Foundation; 2015. 345. https://physiciansforinformedconsent.org/cdc-pink-book-13th-edition-and-appendix-e-2015-combo/.
  34. Centers for Disease Control and Prevention. Washington, D.C.: U.S. Department of Health and Human Services. Hepatitis B: are you at risk? 2013 Jun. https://www.cdc.gov/hepatitis-b/media/FactSheet-HepBAreYouAtRisk.pdf.
  35. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 13th ed. Hamborsky J, Kroger A, Wolfe S, editors. Washington, D.C.: Public Health Foundation; 2015. 154-5. https://physiciansforinformedconsent.org/cdc-pink-book-13th-edition-and-appendix-e-2015-combo/.
  36. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 13th ed. Hamborsky J, Kroger A, Wolfe S, editors. Washington, D.C.: Public Health Foundation; 2015. 120. https://physiciansforinformedconsent.org/cdc-pink-book-13th-edition-and-appendix-e-2015-combo/.
  37. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 13th ed. Hamborsky J, Kroger A, Wolfe S, editors. Washington, D.C.: Public Health Foundation; 2015. 177. https://physiciansforinformedconsent.org/cdc-pink-book-13th-edition-and-appendix-e-2015-combo/.
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Published 2018 Jul; updated 2024 Sep.