Vaccines in Immunocompromised Children

Kathryn M. Edwards MDSarah H. Sell and Cornelius Vanderbilt Chair

Professor of PediatricsVanderbilt University

Nashville, TN, USA

Objectives

• Provide General Recommendations

• Review the burden of vaccine preventable diseases in immunocompromised children

• Review Immune responses to vaccines

• Highlight deficiencies in vaccine uptake

• Present innovative new approaches

General Recommendations Available

• Killed or inactivated vaccines do not represent a danger to immunocompromised persons and generally should be administered as recommended for healthy persons.

• The immune response to vaccines in immunocompromised persons is less than in immunocompetent persons.

• Higher doses or more frequent boosters may be required, but the immune response may still be suboptimal.

• Live vaccines pose safety challenges to the immunocompromised patient and should be avoided.

• Vaccines should not be administered to children receiving treatment with anti-B cell antibody for at least 6 months.

General Principles

• Avoid live vaccines for 3 months after chemotherapy• Wait one month after high daily steroid doses (i.e.

prednisone 20 mg, or 2 mg/kg) in patients taking them for at least 14 days

• Antivirals can interfere with live vaccines– Wait one day after stopping a herpes antiviral to

give Varivax– Wait 2 weeks after giving FluMist to give an

influenza antiviral, if possible

• Household contacts can receive live vaccines

– Can give MMR, Varivax, RotaTeq, and Zostavax to healthy people living with someone who is immunosuppressed

Avoid Live Vaccines in the Immunocompromised

No deaths, 43% had treatment interrupted

Burden of influenza

12% required mechanical ventilation, 6% died

Guidelines for Influenza Vaccination in Patients Undergoing Transplants

• Transplant physicians share responsibility for ensuring patients/household members vaccinated

• Vaccines should be administered prior to transplant

• Inactivated influenza vaccine (IIV) recommended for all patients > 6 months of age. Previously unimmunized children between 6 months to 8 years require 2 doses.

• Live, attenuated influenza vaccine not indicated

• IIV can be administered 6 months after HSCT or as early as 4 months after HSCT during an outbreak; 2 months after SOT or 1 month after SOT during an outbreak

• Vaccines should not be withheld for rejection concerns

Gaps in Practitioner Knowledge and Practice

• 96% of respondent familiar with guidelines

• 74% said that >70% of their patients received influenza vaccines according to the guidelines

• Pharmacy records indicated that only 38% received vaccines > 6 months after transplant, and only 60% within one year after transplant

• Lower immunization rates in minorities

Innovative new approaches to vaccination in immunocompromised Patients

–Adjuvants

–High dose vaccines

–New inactivated vaccines

• Varicella zoster vaccine

• Cytomegalovirus vaccine

Conclusions

• Substantial burden of vaccine preventable illnesses in transplant recipients

• Immune responses to vaccines lower in immunocompromised than in healthy controls

• Vaccine uptake should be increased

• Innovative new approaches to vaccination are available and need to be explored