What to Know About Vaccinations When You’re Chronic

by Carey Rossi Senior Editor

Vaccines dominate the headlines these days, and for good reason: They can help keep us healthy, while helping those around us stay healthy, too. For many, the decision to get vaccinated involves a doctor’s recommendation and a jab in the arm—sometimes on the same day. But for those of us who are living with chronic conditions, the decision about what vaccines to get and when is a more thoughtful exercise. There is more to weigh—types of vaccines, side effects, treatment schedules, etc. With all the chatter over the COVID vaccines, you might be wondering about the shots, too. We asked the experts what chronic people should consider before getting a vaccination.

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Live Vaccines vs. Inactivated Vaccines

Whether a vaccine contains live virus or not is an important consideration, especially among the immunosuppressed crowd. But what does that mean? Live vaccines are as named: they contain a small, weakened amount of live virus. Because they act as if you were naturally infected by the germ that causes the diseases you’re being vaccinated against, they can give you a lifetime of immunity.

On the flip side, there are inactivated vaccines, which are sometimes called killed vaccines. These contain bits and pieces of the germ that causes the diseases you’re being vaccinated against. These vaccines do not offer immunity forever and may require a booster shot or several doses over your lifetime to achieve ongoing protection.

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Other Common Types of Vaccines

Subunit, recombinant, polysaccharide, and conjugate vaccines use specific pieces of the germ that cause a disease, which sets up the immune system to target the germ piece used. These vaccine types are similar to inactivated vaccines.

Toxoid vaccines, the most notable being Tetanus, use the toxin that a disease-causing germ makes and therefore builds immunity to the byproduct of the germ rather than the germ itself.

Viral vector vaccines use a different virus as the organism that delivers protection. This technology was used for the Johnson & Johnson and AstraZeneca COVID-19 vaccines, as well as vaccines for Ebola and Zika viruses.

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The Health of Your Immune System

“There are several issues with people who are immune-suppressed and vaccines,” Peter Katona, M.D., professor of epidemiology and medicine at UCLA’s Fielding School of Public Health and David Geffen School of Medicine in Los Angeles. “One is live vaccines are dangerous to people with compromised immune systems. The other issue is if you're immune-suppressed, your immune response is going to be muted.” While vaccines are safe for most of the population, those who are severely immunosuppressed need to stay clear of live virus vaccines, such as chickenpox, flu (nasal spray version), MMR (the combined vaccine for measles, mumps, rubella), rotavirus, smallpox, and yellow fever, since there is a risk that the viruses can grow uninhibited because the immune system isn’t strong enough to fight them off.

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Your Treatment Timeline

One of the questions Cameron Wolfe, M.B.B.S., who cares for transplant patients and is an associate professor of medicine at Duke University in Durham, NC, receives from his patients is this: I'm about to get chemo or a transplant. Is it better to vaccinate me before these therapies, or is it better for me to move on with the therapies first and then vaccinate me on the other end? “Ideally, there's a month or two in the way so we can make careful decisions,” says Dr. Wolfe. "And depending on the conditions, those answers can be very different.”

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Your Treatment Timeline, continued

For example, if you’re about to have a kidney transplant, that means you're reasonably immunosuppressed, so your response to vaccinations will not be as good going forward. So, it is important that you’re fully vaccinated prior to your transplant. A counter example to this, Dr. Wolfe explains, is if someone presents with certain cancers of lymphomas. In this instance, the urgency is to get their cancer treated. “It really is a very individualized discussion at that point,” Dr. Wolfe says. Talk with your primary care physician or your specialist and ask: "I'm about to get this so-and-so treatment. How do you think I should time my vaccinations?”

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How Old You Are

As we get older, we don’t respond to vaccines as well. “Our immune system becomes more sluggish. And so, to overcome that, we actually have higher-dosed vaccines that give more of a stimulatory oomph to the [immune] response,” Dr. Wolfe says. He often talks to his patients in their 50s and 60s about taking higher-dose versions of some vaccines, such as the flu vaccine, because it can give them a little bit better protection. “This is even at the expense of perhaps some more side effects, because the more your immune system recognizes a bigger dose, the more you might get some early side effects,” he says. Your doctor will discuss whether these higher dose vaccines are an option for you based on your condition and the vaccine.

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Is There a Contraindication?

A contraindication is any condition that would cause an increased risk for adverse events to occur. In most cases, any contraindication—such as pregnancy or illness, is temporary. Chronic conditions are not necessarily contraindications, though certain treatment might be as they can suppress the immune system. As a result, vaccination can happen once the condition that causes the reason not to vaccinate no longer exists. “Medical exemptions are rare,” says Dr. Katona, who is the chair of the infection-control working group for UCLA in Los Angeles. Consult this table from the CDC to see what contraindications exist for which vaccines.

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Or Is There a Precaution?

“There are people who think that asthma is a contraindication, but it is not. Undergoing chemotherapy is not. The biggest problem [for the latter group] is that they won't get a good immune response,” Dr. Katona says. In most cases, he says, chronic conditions are not contraindications but a few may be considered precautions—conditions in which there is an increased risk of a serious adverse effect or an inability of the vaccine to produce immunity. In these cases, the CDC suggests that the vaccines be deferred except when the benefit of protection outweighs the risk of the adverse event. Talk to your doctor to determine the best course of action.

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Consider Whether You Need a Ring of Protection

Especially when you’re chronic, “your best protection may be to vaccinate the people around you,” Dr. Wolfe says. Talk with your family and closest friends to explain that your best protection as a severely immune-suppressed patient is that none of the people you have daily contact with get sick and put you at risk. “Sometimes creating that ring protection around the immunosuppressed or sicker individual actually is often more helpful than vaccinating them, or at least it is complementary,” Dr. Wolfe says.

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