Canadian Immunization Guide: Part 3 - Vaccination of Specific Populations

Immunization of Persons with Chronic Diseases

Updated: July 2015

Introduction

Chronic diseases may increase a person's risk of infection or increase a person's risk of more severe disease should infection occur. There is also an increased risk of nosocomial exposure to vaccine preventable diseases due the increased likelihood of prolonged hospitalization and frequent outpatient visits associated with chronic disease. Therefore, it is important that people with chronic diseases who are immunocompetent be immunized with both live and inactivated vaccines, according to routine immunization schedules. Vaccines may be less immunogenic in this population and additional vaccines, additional doses, or higher dosages of vaccines may be required to provide adequate protection. Ideally, vaccination is best accomplished early in the disease when the response is likely to be similar to other persons of a similar age with no chronic medical condition. If a disease progresses and immunosuppressive therapy is required, vaccine requirements and recommendations may change. Refer to Table 1 for a summary of recommendations for vaccination of persons with chronic diseases. Refer to Immunization of Immunocompromised Persons in Part 3 for information about vaccination of people who are immunosuppressed.

In general, individuals with chronic disease are at higher risk of invasive pneumococcal disease (IPD), influenza and influenza-related complications, and should be immunized using the recommended vaccine and schedule, as noted in Table 1. Refer to Influenza Vaccine and Pneumococcal Vaccine in Part 4 for additional information.

Asplenia or Hyposplenia

Asplenic or hyposplenic people have absent or defective splenic function. This condition can occur as a result of congenital absence of the spleen, surgical removal of the spleen, or medical conditions that result in poor or absent splenic function, such as sickle cell disease or thalassemia major. All people, regardless of age, who have absent or defective splenic function, are at increased risk of fulminant bacteremia, which is associated with a high mortality rate. Risk is highest in the first 2 years following splenectomy but remains elevated for life.

Careful attention should be paid to immunization status when elective surgical splenectomy is planned so that all of the necessary vaccines are administered at least 2 weeks before surgery. In the case of an emergency splenectomy, vaccines are best given 2 weeks after the splenectomy for optimal vaccine responses. If a person is discharged earlier and there is a concern that she or he might not return, vaccines should be given before discharge.

There are no contraindications to the use of any vaccine for people known to be asplenic or hyposplenic. Such persons should receive all routine vaccinations, including annual influenza vaccine. Particular attention should be paid to ensuring that asplenic or hyposplenic individuals of all ages receive recommended Haemophilus influenzae type b (Hib), meningococcal and pneumococcal vaccines, as these individuals are highly susceptible to encapsulated bacteria. Hepatitis A and Hepatitis B vaccines are indicated for those who require repeat transfusions, such as sickle cell anemia. Refer to Influenza Vaccine, Haemophilus Influenzae Type B Vaccine, Meningococcal Vaccine, Pneumococcal Vaccine, Hepatitis A Vaccine, Hepatitis B Vaccine in Part 4 and Table 1 for additional information.

Chronic Renal Disease and Patients on Dialysis

Bacterial and viral infections are a major cause of morbidity and mortality in people with renal disease or who are undergoing chronic dialysis (hemodialysis or peritoneal dialysis). People with chronic renal disease and dialysis may have mild defects in T cell function, while in individuals with nephrotic syndrome, urinary loss of antibody may occur. Because these persons are also in frequent contact with the health care system, they are at greater risk of infection from vaccine preventable diseases.

People with chronic renal disease or those who are undergoing dialysis should receive all routine vaccinations, including annual influenza vaccine. In addition to routine immunization, hepatitis B and pneumococcal vaccines are recommended. Since individuals with impaired renal function may experience a less than optimal response to immunization, higher vaccine doses and re-immunization may be required. Refer to Influenza Vaccine, Hepatitis B Vaccine, Pneumococcal Vaccine and Table 1 for additional information. Refer to Immunization of Immunocompromised Persons in Part 3 for additional information about renal transplant candidates and recipients.

Neurologic Disorders

Neurologic disorders appear at different ages with different manifestations and, therefore, will affect immunization decisions dependent on these factors. Disorders that begin before or during infancy, such as cerebral palsy, spina bifida, seizure disorder, neuromuscular diseases and inborn errors of metabolism, may have symptom onset before the receipt of the vaccines routinely recommended in infancy. Other conditions, such as autism spectrum disorders, acute demyelinating encephalomyelitis, Guillain-Barré syndrome (GBS), transverse myelitis and multiple sclerosis, are known to be diagnosed in childhood and adulthood over the same time period as routine vaccines are administered and may occur before or after the administration of vaccines.

People with neurological or neurodevelopmental conditions should receive all routine immunizations, including annual influenza vaccine, with the exception of repeat doses of any vaccine given within 6 weeks of the onset of an episode of GBS. In addition to routine immunization, pneumococcal vaccines are recommended. Refer to Influenza Vaccine and Pneumococcal Vaccine in Part 4 and Table 1 for additional information.

Chronic Lung Disease

Individuals with chronic lung diseases, such as asthma, chronic obstructive pulmonary diseases (COPD), or cystic fibrosis, are at increased risk of complications of influenza and pneumococcal infection. Those with cystic fibrosis are also at increased risk of complications from varicella infection, which may cause a transient worsening of lung function. Many individuals with more severe chronic lung disease have bacterial colonization due to poor mucociliary clearance and bronchiectasis, and defects in pulmonary macrophage function. Smoking also impairs mucociliary clearance and predisposes to pneumococcal disease.

People with chronic lung disorders, including adult smokers and individuals with bronchopulmonary dysplasia, cystic fibrosis and asthma, should receive influenza vaccine annually in addition to other routine immunization. Pneumococcal vaccines are also recommended. Asthma control should be optimized before receipt of any vaccine. Refer to Influenza Vaccine and Pneumococcal Vaccine in Part 4 and Table 1 for additional information. Refer to Immunization of Immunocompromised Persons in Part 3 for additional information about vaccination of lung transplant candidates and recipients. Refer to Passive Immunizing Agents in Part 5 for information about the use of anti-respiratory syncytial virus (RSV) monoclonal antibody (RSVAb) for RSV prophylaxis in young children with lung disease.

Chronic Heart Disease

In individuals with chronic heart disease, viral and bacterial infections may precipitate cardiac decompensation and lead to hospitalization. There is evidence that giving influenza vaccine to those with coronary artery disease has some protective effect on subsequent cardiac events.

People with cardiac disorders should receive routine immunization, including annual influenza vaccine, as they are at high risk of influenza-related complications. Individuals with chronic heart disease should also receive pneumococcal vaccines. Refer to Influenza Vaccine and Pneumococcal Vaccine in Part 4 and Table 1 for additional information. Refer to Passive Immunizing Agents in Part 5 for information about the use of anti-respiratory syncytial virus (RSV) monoclonal antibody (RSVAb) for RSV prophylaxis in young children with heart disease.

Chronic Liver Disease

Persons with chronic liver disease have impaired phagocyte function and defects in opsonizing antibody. They may also have splenic dysfunction if the liver disease is severe. Hepatic encephalopathy or chronic alcohol consumption may lead to aspiration pneumonia. Alcoholism is also a risk factor for IPD. Newly acquired hepatitis A or hepatitis B in persons who already have chronic liver disease from another cause could lead to more severe disease and rapid hepatic decompensation. Those with ascites have an altered immunoglobulin production and distribution.

People with chronic liver disease should receive routine immunization, including annual influenza vaccine. In addition, people with chronic liver disease should receive pneumococcal, hepatitis A, and hepatitis B vaccines. Vaccination should be completed early in the course of liver disease, as the immune response to vaccine is suboptimal in advanced liver disease. Since individuals with chronic liver disease may experience a less than optimal response to immunization, higher vaccine doses and re-immunization may be required. Refer to Influenza Vaccine, Pneumococcal Vaccine, Hepatitis A Vaccine, and Hepatitis B Vaccine in Part 4 and Table 1 for additional information.

Endocrine and Metabolic Diseases

People with diabetes mellitus have defects in phagocytic and neutrophil function. In addition, they often have complications of diabetes such as cardiovascular, neurovascular, renal and other end-organ dysfunction and are at greater risk of complications from infection. Persons with other metabolic disorders, such as thyroid disorders, or morbid obesity (Body Mass Index of 40 or higher) are also at high risk of influenza-related complications.

Routine immunization, including annual influenza vaccine, is recommended for persons with endocrine and metabolic disorders. In addition to routine immunization, people with diabetes should receive pneumococcal vaccines. It is generally not expected that vaccines would interfere with insulin levels or glucose control. Refer to Influenza Vaccine and Pneumococcal Vaccine in Part 4 and Table 1 for additional information.

Non-Malignant Hematologic Disorders

Non-malignant hematologic disorders include different types of anemia and hemoglobinopathy, as well as bleeding disorders. For further discussion on vaccines recommended for people with anemia due to sickle cell disease, refer to Asplenia or hyposplenia.

Anemia and hemoglobinopathy

People with anemia may be at increased risk of complications from vaccine preventable diseases. In addition to routine immunization, people with different types of anemia or hemoglobinopathy should receive influenza vaccine annually, and if there is a need for repeat transfusions, hepatitis A and hepatitis B vaccines. Refer to Influenza Vaccine, Pneumococcal Vaccine, Hepatitis A Vaccine, and Hepatitis B Vaccine in Part 4 and Table 1 for additional information.

Bleeding disorders

People with bleeding disorders may differ from the normal population with respect to the risk of hematoma formation from parenteral injections and the potentially increased risk of infection as a result of their disease and exposure to blood products. Hemophiliacs and people receiving repeated infusions of blood or blood products should be considered for pre-immunization serologic testing if they have had repeated exposure to blood products.

Before beginning immunization of any child, vaccine providers should ensure that there are no symptoms or signs compatible with an undiagnosed bleeding disorder. If such indicators are present, a diagnosis should be established before commencing immunization. For example, in any male child who has a history of an intramuscular hematoma following an intramuscular injection, an undiagnosed bleeding disorder, such as hemophilia, should be considered. If a disorder is present, it should be optimally managed prior to immunization to minimize the risk of bleeding. For example, hemophiliacs may receive clotting factor concentrates to optimize their clotting factor level before they receive a parenteral vaccine or a passive immunizing agent. Individuals receiving long-term anticoagulation with either warfarin or heparin are not considered to be at higher risk of bleeding complications following immunization and may be safely immunized through either the IM or subcutaneous route as recommended, without discontinuation of their anticoagulation therapy.

Generally there is no evidence of increased risk of bleeding in those with bleeding disorders following IM versus subcutaneous injections. There is some evidence to suggest that IM administration may generally be safe when given with a small gauge needle (23 gauge or smaller) and when firm pressure is applied to the injection site for 5 to 10 minutes. There is also evidence that immunization by the subcutaneous route for vaccine intended for intramuscular administration may be associated with more local reactogenicity and a diminished immune response, compared to the IM route.

In addition to routine immunization, people with bleeding disorders should receive influenza vaccine annually, and if there is a need for repeat transfusions, hepatitis A and hepatitis B vaccines. Refer to Influenza Vaccine, Hepatitis A Vaccine, and Hepatitis B Vaccine in Part 4 and Table 1 for additional information.

Chronic Inflammatory Diseases

This population includes persons with inflammatory arthropathies, such as systemic lupus erythematosus [SLE], rheumatoid arthritis and juvenile arthritis; inflammatory dermatologic conditions, such as psoriasis, severe atopic dermatitis and eczema; and inflammatory bowel disease, such as Crohn's disease and ulcerative colitis. Infections are one of the most common causes of morbidity, hospitalization and death in these individuals. An increased risk of infection and infection-related complications is thought to be due to both an altered immune response associated with the autoimmune condition itself and to the immunosuppressive nature of the treatments required to control the underlying inflammatory condition.

Individuals with autoimmune disease not being treated with immunosuppressive drugs are not considered significantly immunocompromised and can receive routine immunization, including live vaccines, following consultation with a physician. Rheumatic disease modifying agents, such as hydroxychloroquine, sulfasalazine, or auranofin are not generally identified as immunosuppressive.

Individuals with chronic inflammatory diseases should receive, in addition to routine immunization, influenza vaccine annually. For individuals with dermatologic disorders, care should be taken to not administer vaccine into affected areas, as this procedure may exacerbate the condition. Refer to Influenza Vaccine in Part 4 and Table 1 for additional information. Refer to Immunization of Immunocompromised Persons in Part 3 for a list of immunosuppressive medications and information regarding immunization of people with chronic inflammatory diseases who are being treated with immunosuppressive therapies.

Cancer

People with cancer have a higher risk of contracting infectious diseases and a higher risk of developing complications, likely because many cancers and their treatments affect the immune system. Therefore, it is important that children and adults with cancer receive protection from vaccine preventable diseases whenever possible. Generally, cancer alone is not sufficient to cause immunosuppression to the extent that an individual cannot receive live vaccines. Because chemotherapy may lead to an immunocompromised state, immunization should be completed before beginning chemotherapy if possible. Recommended vaccines will depend on the type of cancer and the type of treatment. For hematologic cancers or for people on immunosuppressive therapies, refer to Immunization of Immunocompromised Persons in Part 3. It is important to assess and optimize the vaccination status of anyone close to people with cancer to reduce the risk of exposure to vaccine preventable diseases. Refer to Close Contacts for additional information.

Chronic Salicylate Therapy in Children

Individuals less than 18 years of age receiving low doses of salicylate therapy (e.g., acetylsalicylic acid [aspirin, ASA]) are not considered to be at increased risk of bleeding complications following immunization. However, for children and adolescents on chronic salicylate therapy, special consideration must be given when administering live influenza and varicella vaccines because of an association between wild-type infection, salicylate therapy and Reye's syndrome. Reye's syndrome, which causes damage to the brain and liver, is a rare complication that most commonly occurs in children taking ASA at the time of wild-type infection with these viruses.

Children and adolescents with conditions treated for long periods with ASA are at high risk of influenza-related complications and should receive inactivated influenza vaccine annually. LAIV should not be administered to children currently receiving ASA. Refer to Influenza Vaccine in Part 4 for additional information.

Health care providers should weigh the theoretical risks associated with varicella vaccine against the known risks associated with wild-type varicella infection. Because adverse events have not been reported with the use of salicylates after varicella immunization, people with conditions requiring chronic salicylate therapy should be considered for immunization, with close subsequent monitoring. Refer to Varicella (Chickenpox) Vaccine in Part 4 for additional information.

Other Conditions

People who have received a cochlear implant are at increased risk for meningitis and for otitis media. People with cochlear implants or those who are receiving cochlear implants should receive all age appropriate vaccinations, including Pneu-C-13, Hib and influenza vaccines. Children 24 months and older and adults should also receive a single dose of Pneu-P-23 vaccine. Refer to Influenza Vaccine, Pneumococcal Vaccine, and Haemophilus Influenzae Type B Vaccine in Part 4 for additional information.

Co-Morbidities

Guidance on immunization for those with more than one chronic condition is an emerging area of inquiry; evidence to support guidance on immunization of people with co-morbidities is lacking. There is some evidence that co-morbidities may have additive risk for complications from vaccine preventable diseases, such as influenza. As a general principle, when considering immunization of people with co-morbidities, all conditions and medications should be considered in relation to the indications, precautions and contraindications for each vaccine.

Close Contacts

Up-to-date routine immunizations, including annual influenza vaccine, are recommended for household members and other close contacts, including health care workers, of people with chronic diseases. Refer to Immunization of Workers and Immunization of Immunocompromised Persons in Part 3 for additional information.

Table 1: Vaccination of Persons with Chronic Disease
Vaccine Chronic Disease
Asplenia/
hyposplenia
Renal diseases/
dialysis
Neurologic disordersTable 1 footnote 1 Lung disease Liver disease Endocrine/
metabolic diseases
Heart disease Chronic inflammatory diseases Non-malignant hematologic disordersTable 1 footnote 2
Inactivated vaccines
Cholera and travellers' diarrhea Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated
Diphtheria Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use
Haemophilus influenzae type b (Hib) Recommended for all ages Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use
Hepatitis A Use if indicatedTable 1 footnote 3 Use if indicated Use if indicated Use if indicated Recommended Use if indicated Use if indicated Use if indicated Recommended for hemophiliacs and people receiving repeated infusions of blood or blood products
Hepatitis B Routine useTable 1 footnote 3 RecommendedTable 1 footnote 4 Routine use Routine use RecommendedTable 1 footnote 5 Routine use Routine use Routine use Recommended for hemophiliacs and people receiving repeated infusions of blood or blood products
HPV Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use
Influenza (TIV or QIV)

Recommended annually

Children: QIV should be usedTable 1 footnote 6. If QIV is not available, TIV should be used.

           

Recommended annually if immuneosuppressed

Children: QIV should be usedTable 1 footnote 6. If QIV is not available, TIV should be used.

Recommended annually for people with anemia or hemoglobinopathy

Children: QIV should be usedTable 1 footnote 6. If QIV is not available, TIV should be used.

Japanese encephalitis Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated
Meningococcal conjugate quadrivalent Recommended for all agesTable 1 footnote 7 Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use
Multicomponent meningococcal Consider useTable 1 footnote 8                
Pertussis Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use
Pneumococcal conjugate 13-valent Recommended for all ages

Children: recommended

Adults with nephrotic syndrome: recommended

Children: recommended Children: recommended Children: recommended Children: recommended Children: recommended Recommended if immunosuppressed Children and adults with hemoglobinopathy: recommended
Pneumococcal polysaccharide 23-valent Recommended for children 2 years of age and older and adultsTable 1 footnote 9 Recommended for children 2 years of age and older and adultsTable 1 footnote 9 Recommended for children 2 years of age and older and adultsTable 1 footnote 10 Recommended for children 2 years of age and older and adults Recommended for children 2 years of age and older and adultsTable 1 footnote 9 Recommended for those with diabetes Recommended for children 2 years of age and older and adults Recommended if immunosuppressedTable 1 footnote 9 Recommended for children 2 years of age and older and adults with hemoglobinopathy
Polio (inactivated) Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use
Rabies Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated
Tetanus Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use
Typhoid (inactivated) Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated
Live vaccines
BCG Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated if no immune suppression. Contraindicated if extensive skin disease Use if indicated
Herpes zoster Use if indicated Routine use Routine use Routine use Routine use Routine use Routine use Use if indicated if no immune suppression Routine use
Influenza (LAIV)

Children: Insufficient evidence to preferentially recommend LAIVTable 1 footnote 11

Adults: TIV or QIV preferredTable 1 footnote 11

               
Measles-mumps-rubella Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use if no immune suppression Routine use
Rotavirus Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use if no immune suppression Routine use
Smallpox Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Contraindicated in non-outbreak situation Contraindicated in non-outbreak situation for people with dermatologic conditions or immune suppression Use if indicated
Typhoid (live) Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated if no immune suppression Use if indicated
Varicella (univalent) Routine useTable 1 footnote 12 Routine useTable 1 footnote 12 Routine use Routine useTable 1 footnote 13 Routine use Routine use Routine use Use if indicated if no immune suppression Routine use
Yellow feverTable 1 footnote 14 Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated if no immune suppression Use if indicated

Selected References

  • American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW et al. (editors). Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.
  • Castagnola E, Fioredda F. Prevention of life-threatening infections due to encapsulated bacteria in children with hyposplenia or asplenia: a brief review of current recommendations for practical purposes. Eur J Haematol 2003;71(5):319-26.
  • Centers for Disease Control and Prevention. General Recommendations on Immunization
    Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2011;60(2):1-61.
  • 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 Morb Mortal Wkly Rep 1993;42(RR-4):1-18.
  • Committee to Advise on Tropical Medicine and Travel. The immunocompromised traveller. Can Commun Dis Rep 2007;33(ACS-4):1-24.
  • Crawford NW, Bines JE, Royle J et al. Optimizing immunization in pediatric special risk groups. Expert Rev Vaccines 2011;10:175-86.
  • Melles DC, de Marie S. Prevention of infections in hyposplenic and asplenic patients: an update. Neth J Med 2004;62(2):45-52.
 

Chronic renal diseases/dialysis

  • Fivush BA, Neu AM. Immunization guidelines for pediatric renal disease. Semin Nephrol 1998;18(3):256-63.
  • Neuhauss TJ. Immunization in children with chronic renal failure: a practical approach. Pediatr Nephrol 2004;19(12):1334-39.
  • Rangel MC, Coronado VG, Euler GL et al. Vaccine recommendations for patients on chronic dialysis. Semin Dial 2000;13(2):101-107.
 

Endocrine and metabolic diseases

  • Lin YC, Lin YC, Chen TW et al. Abnormal thyroid function predicts mortality in patients receiving long-term peritoneal dialysis: a case-controlled longitudinal study. J Chin Med Assoc 2012 Feb;75(2):54-9.
 

Chronic liver disease

  • Keeffe EB. Acute hepatitis A and B in patients with chronic liver disease: prevention through vaccination. Am J Med 2005;118(Suppl 10A):S21-27.
 

Non-malignant hematologic disorders

  • Balkan C, Kavakli K, Kutukculer N et al. The effect of clotting factor concentrates on the immune system in HIV-negative haemophila. Haemophilia 2005;11:366-370.
  • Casajuana J, Iglesias B, Fabregas M et al. Safety of intramuscular influenza vaccine in patients receiving oral anticoagulation therapy: a single blinded multi-centre randomized controlled clinical trial. BMC Blood Disord 2008;8:1.
  • Evans DI, Shaw A. Safety of intramuscular infection of hepatitis B vaccine in hemophiliacs. BMJ 1990;300:1694-95.
  • Linglof T, van Hattum J, Kaplan KM et al. An open study of subcutaneous administration of inactivated hepatitis A vaccine (VAQTA) in adults: safety, tolerability and immunogenicity. Vaccine 2001;3968-71.
  • Makris M, Conlon CP, Watson HG. Immunization of persons with bleeding disorders. Haemophilia 2003;9(5):541-46.
  • Stelle M, Cochrane A, Wakefield C et al Hepatitis A and B immunization for individuals with inherited bleeding disorders. Haemophilia 2009;15:437-47.
  • Van Aalsbury R, van Genderen PJ. Vaccination in patients on anticoagulants. Travel Med Infect Dis 2011;9: 310-11.
 

Chronic inflammatory diseases

  • Crawford NW, Bines JE, Royle J et al. Optimizing immunization in pediatric special risk groups. Exper Rev Vaccines 2011;10:175-86.
  • Heijstek MW, van Gageldonk PG, Berbers GA et al. Differences in persistence of measles, mumps, rubella, diphtheria and tetanus antibodies between children with rheumatic disease and healthy controls: a retrospective cross-sectional study. Ann Rheum Dis 2012;71:948-54.
  • McCarthy EM, Azeez MA, Fitzpatrick FM et al. Knowledge, Attitudes and clinical practice of rheumatologists in vaccination of the at risk rheumatology patient population. J Clin Rheum 2012;18:237-41.
  • Morin MP, Quach C, Fortin E et al. Vaccination coverage in children with juvenile idiopathic arthritis followed at a paediatric tertiary care centre. Rheumatology 2012;276-90.
  • Nordgaard-Lassen I. Dahlerup FJ, Belard E et al. Guidelines for screening, prophylaxis, and critical information prior to initiating anti-TNF-Alpha treatment. Dan Med J 2012;59:1-11.
 

Other conditions

  • Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices. Pneumococcal vaccination for cochlear implant candidates and recipients: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2003 Aug 8;52(31):739-40.
  • Natarajan P, Cannon CP. Myocardial infarction vaccine? Evidence supporting the influenza vaccine for secondary prevention. Eur Heart J 2011;32:1701-03.
  • Rubin LG. Prevention and treatment of meningitis and acute otitis media in children with cochlear implants. Otol Neurotol 2010 Oct;31(8):1331-3.
  • Ruggiero A, Battista A, Coccia P et al. How to manage vaccinations in children with cancer. Pediatr Blood Cancer. 2011 Dec 15;57(7) 104-8.
  • Schanzer DL, Langley JM, Tam TW. Co-morbidities associated with influenza-attributed mortality, 1994-2000, Canada. Vaccine. 2008 Aug 26;26(36):4697-703.
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