CHF INCLEN ADVAC Vaccination in Special Situations: Break-out sessions. Group B

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1 CHF INCLEN ADVAC 2011 Vaccination in Special Situations: Break-out sessions Group B 1

2 Group B. Moderator: Dr. Rohit Agrawal Expert: Dr. Walter Orenstien 2

3 Learning objectives: What are the special situation that warrant change in immunization practices? What are the issues to confront with while immunizing an immunocompromized child? Different immunocompromized states and vaccination recommendations: The recommendations for vaccinating an HIV positive child; Issues related to immunizing a preterm/lbw infant How to deal with issues like lapsed immunization, catch up immunization, immunization for travelers, during pregnancy & illness, elderly, etc? Immunization of children with chronic diseases, with malignancy, with asplenia, with organ transplant, etc Immunization of children on steroid therapy, recd antibodies containing products Recommendations on interchangeability of vaccine brands 3

4 Vaccination in Immunocompromized children: Dilemmas & reality!! 4

5 The Dilemma: 5

6 The Reality: 6

7 Vaccinations not optimally used in our immunocompromised patients Disease oriented approach Ignorance Fear of vaccine-associated risks Perception of insufficient efficacy (why stimulate a compromised immune system ) 7

8 The Issues: Basis of Vaccination in Immunocompromised (IC): Greater need for immunization Higher Susceptibility IC Lower immunogenicity / efficacy Adverse effects with live vaccines 8

9 General Principles: In severe immunodeficiency all live vaccines contraindicated. In mild / moderate?? All inactivated vaccines may be given but immunogenicity and efficacy low Higher doses, more no. of doses may be required (Hep. B) Antibody titers should be checked post immunization. Regular boosters may be needed 9

10 General Principles: Household contacts of IC should not receive transmissible vaccines such as OPV All household contacts should be fully immunized including varicella & influenza to reduce risk of transmission to the IC Immunoglobulins (RIG, TIG, HIG) may be needed in some situations. IAP recommended Vaccines like pneumococcal, varicella, hepatitis A, inactivated influenza should be given if resources permit Insufficient data on safety and efficacy of Rotavirus vaccine in IC 10

11 Immune Responses & CD4+ Count: At what level Immune suppression develops? 11

12 Immune Responses & CD4+ Count: At what level Immune suppression develops? Conserved- no immunosuppression when: CD4+ T lymphocytes >25% Moderate immunosuppression when: CD4+ T lymphocytes 15-24% Severe immuno-suppression (Impaired, absent) when: CD4+ T lymphocytes <15% 12

13 IMMUNOCOMPROMISED CONDITIONS A. PRIMARY (CONGENITAL) IMMUNODEFICIENCIES B. ACQUIRED IMMUNODEFICIENCIES 13

14 What are Primary Immunodeficiency States? 14

15 What are Primary Immunodeficiency States? Primary Immunodeficiency States B-lymphocyte defects T-lymphocyte defects Phagocytic function disorders Complement deficiency 15

16 WHAT ARE ACQUIRED IMMUNODEFICIENCIES? 16

17 WHAT ARE ACQUIRED IMMUNODEFICIENCIES? ACQUIRED IMMUNODEFICIENCIES HIV Chronic liver diseases Malignancies & chronic granulomatous diseases Transplant recipients Solid organ transplant BMT Children with malignancies on Immunosuppressive therapy - Steroids, CXT, RXT, Asplenic children 17

18 B-lymphocyte defects: OPV Contraindicated in all these situations All live bacterial (BCG & Oral Typhoid) & - contraindicated Live Viral (MMR, Measles & Varicella) vaccines- Caution Inactivated vaccines can be given but of uncertain efficacy Pneumococcal and influenza particularly recommended 18

19 T-lymphocyte defects All live vaccines are contraindicated!! Inactivated vaccines may be given but efficacy depends on severity of immunocompromise 19

20 T -lymphocyte defects (cell mediated and humoral ) SCID ( severe combined immunodeficiecy) Complete Di George syndrome NO LIVE VACCINE All vaccines ineffective 20

21 T -lymphocyte defects (cell mediated and humoral ) partial Di George syndrome Wiskott Aldrich syndrome Ataxia telangiectasia NO LIVE VACCINE inactivated vaccines may be given 21

22 Phagocytic function disorders Eg CGD, LAD, MPO deficiency All live bacterial (BCG and oral typhoid) vaccines are contraindicated!! Live viral vaccines can be administered Consider Influenza vaccine to prevent secondary bacterial infections 22

23 Complement deficiency All vaccines can be safely administered More prone to pneumococcal & meningococcal infections! C1-4 (early complement): all vaccines are effective; pneumo + meningo recommended C5-9, Properdin, Factor B: all vaccines are effective; meningo recommended 23

24 Secondary Immunodeficiency states HIV Chronic liver diseases Malignancies & chronic granulomatous diseases Transplant recipients Solid organ transplant BMT Immunosuppressive therapy - Steroids, CXT, RXT, Asplenic children 24

25 Immunization of Preterms/LBWs: All vaccines may be administered as per schedule according to the chronological age irrespective of birth weight or period of gestation. BCG and birth dose of OPV can be safely and effectively given to low birth weight/preterm babies after stabilization and preferably at the time of discharge. In babies < 2 kg, the birth dose of hepatitis B vaccine should be delayed for 1 month after birth as immunogenicity is lower if given earlier. 25

26 Vaccination of patients receiving steroids Killed vaccines are fine Live vaccines are safe if daily dose <20 mg / day (prednisone) in more than 10 kg or (< 2 mg/kg in less than 10 kg) > 2 mg/kg or > 20 mg / day for less than 2 weeks alternate day therapy Inhaled or topical steroids OUTSIDE OF THESE CONDITIONS NO LIVE VACCINE (until 1 month after discontinuation of corticoids) 26

27 Vaccination of the patient with cancer / chemotherapy / radiotherapy VACCINE Indic Catchup DTP YES Hepatitis B YES Pneumococcus YES Influenza YES Varicella YES * MMR YES * *Before initiation (!!!) or > 3-6 months after chemotherapy! Optimal period of immunization Decreased immunogenicity Increased risk of complications All live vaccines should be avoided during and at least 3 months after chemotherapy & radiotherapy 27

28 Immunization in relation to antibody containing products Inactivated vaccines can be safely administered Live vaccines including MMR & Varicella should be avoided for 3 months Antibody containing products should be avoided for 2 weeks after these vaccinations Oral Typhoid vaccine, LAIV, OPV & Yellow fever may be given at any time Rota virus vaccine should be avoided for 6 weeks 28

29 Immunization in H/O Allergy Vaccines contraindicated with H/O Serious Hypersensitivity / Anaphylaxis In H/O egg allergy influenza & yellow fever vaccines contraindicated but measles, MMR may be given. H/O any hypersensitivity should be cautious vaccination with JE Mild reactions not contraindications to vaccinations Resuscitation equipment should be kept standby 29

30 Questions 30

31 Q 1. A preterm infant weighing 1900 gms born after 34 week of gestation to a HBsAG +ve mother. What should be the most appropriate schedule pertaining to Hep-B vaccination: 1. HBIG within 12 hrs of birth + 3 more doses of Hep-B vaccine at 1, 2, & 6 mo 2. HBIG within 48 hrs of birth + first dose of Hep-B vaccine + 2 more doses of Hep-B vaccine at 1, & 6 mo 3. HBIG within 48 hrs of birth + first dose of Hep-B vaccine + 3 more doses of Hep-B vaccine at 1, 2, & 12 mo 4. HBIG within 12 hrs of birth + first dose of Hep-B vaccine + 3 more doses of Hep-B vaccine at 1, 2, & 6 mo 5. HBIG within 7 days of birth + 3 more doses of Hep-B vaccine at 6, 10 & 14 weeks of age. 31

32 Q 1. A preterm infant weighing 1900 gms born after 34 week of gestation to a HBsAG +ve mother. What should be the most appropriate schedule pertaining to Hep-B vaccination: 1. HBIG within 12 hrs of birth + 3 more doses of Hep-B vaccine at 1, 2, & 6 mo 2. HBIG within 48 hrs of birth + first dose of Hep-B vaccine + 2 more doses of Hep-B vaccine at 1, & 6 mo 3. HBIG within 48 hrs of birth + first dose of Hep-B vaccine + 3 more doses of Hep-B vaccine at 1, 2, & 12 mo 4. HBIG within 12 hrs of birth + first dose of Hep-B vaccine + 3 more doses of Hep-B vaccine at 1, 2, & 6 mo 5. HBIG within 7 days of birth + 3 more doses of Hep-B vaccine at 6, 10 & 14 weeks of age. 32

33 Q.2. A preterm born at 30 weeks gestation weighing 1200 grams exposed to varicella after 2 weeks of birth. What is the best option? 1. Give VZIG 2. Do not give 3. Check the mothers serum for anti varicella IgG and if negative - give 33

34 Q.2. A preterm born at 30 weeks gestation weighing 1200 grams exposed to varicella after 2 weeks of birth. What is the best option? 1. Give VZIG 2. Do not give 3. Check the mothers serum for anti varicella IgG and if negative - give 34

35 Q.3. In a preterm / VLBW baby BCG should be given at Birth 2.At 15 days 3.At 6 moths 4.Any of the above 35

36 Q.3. In a preterm / VLBW baby BCG should be given at Birth 2.At 15 days 3.At 6 moths 4.Any of the above 36

37 Q.4. In a preterm, pneumococcal, rota virus & influenza vaccine should not be given True / False 37

38 Q.4. In a preterm, pneumococcal, rota virus & influenza vaccine should not be given True / False 38

39 Q 5. A 5-yr-old severe asthmatic child weighing 16 kg is on alternate day prednislone (30 mg) along with inhaled fluticasone 400 microgram per day for last 5 months. His second dose of MMR is due now. What should be the best option? 1. Discontinue oral steroids and wait for another 4 weeks before administering the vaccine. 2. Discontinue both oral and inhaled steroids and administer the vaccine 3. Postpone the dose of the vaccine till completion of oral and inhaled steroid therapy 4. Administer the vaccine and continue the steroid therapy as before. 39

40 Q 5. A 5-yr-old severe asthmatic child weighing 16 kg is on alternate day prednislone (30 mg) along with inhaled fluticasone 400 microgram per day for last 5 months. His second dose of MMR is due now. What should be the best option? 1. Discontinue oral steroids and wait for another 4 weeks before administering the vaccine. 2. Discontinue both oral and inhaled steroids and administer the vaccine 3. Postpone the dose of the vaccine till completion of oral and inhaled steroid therapy 4. Administer the vaccine and continue the steroid therapy as before. 40

41 Q 6. A 15 mo-old male nephrotic child weighing 10 kg who is on daily prednisolone (20mg/D) for last 5 weeks comes to you for his MMR-Varicella vaccinations. What would you do? 1. Administer both the vaccines at same visit and ask the parents to continue steroids treatment as before. 2. Ask parents to come after one month of discontinuation of steroid therapy. 3. Administer both the vaccines and ask parents to discontinue steroids treatment. 4. Ask parents to come after three months of discontinuation of steroid therapy. 41

42 Q 6. A 15 mo-old male nephrotic child weighing 10 kg who is on daily prednisolone (20mg/D) for last 5 weeks comes to you for his MMR-Varicella vaccinations. What would you do? 1. Administer both the vaccines at same visit and ask the parents to continue steroids treatment as before. 2. Ask parents to come after one month of discontinuation of steroid therapy. 3. Administer both the vaccines and ask parents to discontinue steroids treatment. 4. Ask parents to come after three months of discontinuation of steroid therapy. 42

43 Q 7. A 5 year-old-male child with chronic ITP who has received a course of IVIG one month back has brought to you for vaccination against Hep-A, MMR and varicella. What would be your advice to him? 1. Administer a brand of inactivated Hep-A vaccine and ask parents to bring him after 2 months for MMR and Varicella vaccinations. 2. Administer all the three vaccines. 3. Advice parents to bring the child after 5 months for all these vaccinations. 4. Check his bleeding profile including platelet counts and administer all the vaccines through subcutaneous route. 43

44 Q 7. A 5 year-old-male child with chronic ITP who has received a course of IVIG one month back has brought to you for vaccination against Hep-A, MMR and varicella. What would be your advice to him? 1. Administer a brand of inactivated Hep-A vaccine and ask parents to bring him after 2 months for MMR and Varicella vaccinations. 2. Administer all the three vaccines. 3. Advice parents to bring the child after 5 months for all these vaccinations. 4. Check his bleeding profile including platelet counts and administer all the vaccines through subcutaneous route. 44

45 Q 8. A 4 year-old child with acute leukemia who is on continuation phase of chemotherapy has not received varicella vaccine earlier. The parents now want him to be immunized against varicella as a mini outbreak has erupted in the neighbourhood. What would be your advice to the parents? 1. Administer varicella vaccine. 2. Administer varicella vaccine after 3 months of discontinuation of chemotherapy. 3. Check for anti-varicella IgG and administer VZIG (if seronegative) and varicella vaccine after 3 months of discontinuation of chemotherapy 4. Administer VZIG and varicella vaccine after 4 weeks of discontinuation of chemotherapy. 5. None of the above. 45

46 Q 8. A 4 year-old child with acute leukemia who is on continuation phase of chemotherapy has not received varicella vaccine earlier. The parents now want him to be immunized against varicella as a mini outbreak has erupted in the neighbourhood. What would be your advice to the parents? 1. Administer varicella vaccine. 2. Administer varicella vaccine after 3 months of discontinuation of chemotherapy. 3. Check for anti-varicella IgG and administer VZIG (if seronegative) and varicella vaccine after 3 months of discontinuation of chemotherapy 4. Administer VZIG and varicella vaccine after 4 weeks of discontinuation of chemotherapy. 5. None of the above. 46

47 Q weeks old infant has received 2 does of rotateq vaccine. Now the parents are transferred to the town where only rotarix brand is available. What is the best option? 1. Give 3 rd dose in the form of rotarix 2. Defer vaccination till the original brand is available 3. Cancel the 3 rd dose 4. Restart the vaccination with the new brand. 47

48 Q weeks old infant has received 2 does of rotateq vaccine. Now the parents are transferred to the town where only rotarix brand is available. What is the best option? 1. Give 3 rd dose in the form of rotarix 2. Defer vaccination till the original brand is available 3. Cancel the 3 rd dose 4. Restart the vaccination with the new brand. 48

49 Q weeks old brought for age appropriate immunization. Parents give history of severe allergic reaction to previous dose of DTwP. What will you do? 1. Prefere DTaP 2. Skip DTaP / DTwP and give all other vaccines 3. Give DTwP and keep ressuscitation kit ready 4. Abandon all vaccination 49

50 Q weeks old brought for age appropriate immunization. Parents give history of severe allergic reaction to previous dose of DTwP. What will you do? 1. Prefere DTaP 2. Skip DTaP / DTwP and give all other vaccines 3. Give DTwP and keep ressuscitation kit ready 4. Abandon all vaccination 50

51 Thank You!!! 51

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