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Vaccines in Immunocompromised Children
Kathryn M. Edwards MDSarah H. Sell and Cornelius Vanderbilt Chair
Professor of PediatricsVanderbilt University
Nashville, TN, USA
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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
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General Recommendations Available
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• 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
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• 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
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No deaths, 43% had treatment interrupted
Burden of influenza
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12% required mechanical ventilation, 6% died
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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
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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
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Innovative new approaches to vaccination in immunocompromised Patients
–Adjuvants
–High dose vaccines
–New inactivated vaccines
• Varicella zoster vaccine
• Cytomegalovirus vaccine
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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