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قَالوُا سُبحَانَك لاَعِلمَ لنَا إلا مَاعَلمتَناَ إنكَ أَنَتَ العَلِيمُ الحَكِيمُ

بسم الله الرحمن الرحيم. قَالوُا سُبحَانَك لاَعِلمَ لنَا إلا مَاعَلمتَناَ إنكَ أَنَتَ العَلِيمُ الحَكِيمُ. صدق الله العظيم  (سورة البقرة – الآية 32). Immunization in the immunocompromised children. guidelines By Prof. MERVAT HESHAM. Who is the immunocompromised.

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قَالوُا سُبحَانَك لاَعِلمَ لنَا إلا مَاعَلمتَناَ إنكَ أَنَتَ العَلِيمُ الحَكِيمُ

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  1. بسم الله الرحمن الرحيم قَالوُاسُبحَانَكلاَعِلمَ لنَا إلا مَاعَلمتَناَ إنكَ أَنَتَ العَلِيمُ الحَكِيمُ صدق الله العظيم  (سورة البقرة – الآية 32)

  2. Immunization in the immunocompromised children guidelines By Prof. MERVAT HESHAM

  3. Who is the immunocompromised 1ry immunodeficiency Specific: B cells T cells Phagocytic Complement Non specific: Skin GIT losses

  4. 2ry immunodeficiency • Preterm - Nutritional • -DM - Malignancy • -Hematological -Therapeutic • -Hepatic - Renal • -Infections - Irradiation • -Transplantation

  5. Recommended childhood immunization schedule EPI by WHO BCG At birth within 3 months + 4-6 y DPT 2 – 4 – 6 18 months + 4y DT 10Y Polio 2 – 4 – 6 18 months + booster doses Hepatitis 2 – 4 – 6 or [0 – 1 – 6 M] Measles 9 months MMR 15 months + 4 – 6 y Hib 2 – 4 – 6 +15 months

  6. Varicella 12 months..on-if >13 y 2 doses 1 m. apart Hepatitis A 2 y..on – 2 dosesMeningeococcal 2.5 y + booster 2 yearsInfluenza v.6 months + yearly

  7. general principles relate to immunisation of siblings or other close contacts *Avoid administration of live vaccines (except MMR and BCG) to siblings of immunocompromised patients. *it is strongly recommended that siblings should be given MMR to reduce the patient’s risk of exposure to wild measles * Patients should avoid close physical contact with children vaccinated with OPV for approximately 4-6 weeks following administration

  8. *Killed or inactivated vaccines do not represent a danger to immunocompromised persons. *For specific immunocompromising conditions (e.g., asplenia, renal failure,), such patients may be at higher risk for certain diseases, and additional vaccines, particularly bacterial polysaccharide vaccines {Haemophilus influenzae type b (Hib), pneumococcal and meningococcal}, are recommended for them .

  9. Guidelines of vaccination 1- Primary Immunodeficiency

  10. B-T lymphocyte [except Ig A] *OPV *Measles *MMR *Varicella Complement & phagocytic Splenic dysfunction & Asplenia All vaccines *Pneumococcal *Meningeococcal *Hib Contra indicated Allowed Indicated

  11. Guidelines of vaccination 2-Preterm

  12. All vaccines–usual doses–chronologic age Except BCG <2 kgm wait 40 days (subcutaneous spread) DPT -Neurologically wait unstable -seizure DT

  13. Poliomyelitis -IPV 2 doses -if still in nursery NO OPV to avoid contacts -give on disharge Hepatitis HBsAg +ve mother HBsAg –ve mother V+HBIG >2Kg <2 Kg vaccine no

  14. Guidelines of vaccination 3-Nutritional deficiency

  15. Except 1ry immunodeficiency Infections:TB, Measles All vaccines – usual doses – chronologic No live vaccines

  16. Guidelines of vaccination 4-Oncology

  17. Previous vaccination retain response Recent vaccination Booster after remission

  18. N.B Patients vaccinated while on immunosuppressive therapy or in the 2 weeks before starting therapy should be considered unimmunized and should be revaccinated at least 3 months after discontinuation of therapy

  19. In Oncology Not to vaccinate ! Live vaccines (OPV – BCG – MMR – Typhoid ) in patients actively receiving treatment, and for 6 months following cessation of treatment.

  20. Immunisation during and until six months after completion of treatment *During treatment, administration of non-live vaccines provided that the child’s general condition is stable (ie free from infection and major organ toxicity) and is expected to stay so for 3 weeks from immunisation. *Influenza vaccine is recommended annually

  21. Immunisation six months and later after completion of treatment *administer an additional booster of diphtheria, tetanus, acellular pertussis, IPV, Hib, MeningoC and MMR *If patient has previously had BCG, and is considered to be in a high risk group for tuberculosis, check tuberculin test and if negative, revaccinate. *If patient has not previously had BCG, immunise according to local policy .

  22. In Oncology Extravaccines Hepatitis A 2 doses : 6 months apart-In chronic liver diseases B, C with elevated enzymes -In remission 3 months off therapy

  23. Varicella Zoster V. 12 months – 13 y>13 years1 dose2 doses - 1 month apart -Highly immunogenic with protection 90% -In remission for at least 1 year -Lymphocytic count >700 plat >100.000 day before -no steroids are given for the following2 weeks. -Stop chemotherapy 2 w before & 2 w after ??

  24. In Oncology Double dose in Hepatitis B V During radiotherapy No Live vaccines as in chemotherapy

  25. Guidelines of vaccination 5-Corticosteroid therapy Live vaccines Topical Respiratory Eye-skin Short term V Long term No Physiologic Congenital adrenalhyperplasia V

  26. 5-Corticosteroid therapy Low dose Daily / alternate <5 days <2mg/kg V High dose >2 mg/kg <14 d stop 2 w >14 d stop 1 m If otherwise immunocompromised follow guidelines

  27. N.B Physicians should wait at least 3 months after discontinuation of therapy before administering a live-virus vaccine to patients who have received high-dose, systemic steroids for greater than or equal to 2 weeks.

  28. Guidelines of vaccination 6-Transplant patients A. solid organ transplantation before transplantation • • Ensure that the child is fully up to date with routine primary and (where relevant) booster immunisations. • • Varicella zoster vaccine should be given in non-immune patients. • • Children undergoing haemodialysis whilst awaiting renal transplantation should be given hepatitis B vaccine if they have not already received it.

  29. 6-Transplant patients A. solid organ transplantation after transplantation *Avoid all live vaccines *Pneumococcal and Influenzavaccine should be given *Consider giving varicella zoster vaccine to seronegative family members to provide indirect protection for susceptible patients.

  30. B.Re-immunisation of allogeneic HSCT recipients • 12 months after a HLA-identical sibling donor allogeneic or a syngeneic HSCT. • 18 months after any other allogeneic HSCT. • Providing that: 1- there is no evidence of active chronic GVHD. 2- the child has been off all immunosuppressive treatment (eg steroids, cyclosporin A) for at least 6 months (12 months before administering any live vaccines), and • the child has been off IVIg for at least 3 months. • However, in patients with chronic GVHD not receiving IVIg, consider the use of non-live vaccines .

  31. At 12 months post-HSCT, administer • Diphtheria, tetanus, acellular pertussis – 3 doses at monthly intervals.8-10 • IPV - 3 doses at monthly intervals. • Hib - 3 doses at monthly intervals. • MeningoC - 3 doses at monthly intervals . At 15 months post-HSCT, administer Pneumococcal vaccine At 18 and 24 months post-HSCT, administer MMR (providing that at least 12 months off all immunosuppressive treatment ) At 24 months post-HSCT, administer • Polysaccharide pneumococcal vaccine • Every autumn, administer Influenza vaccine

  32. Guidelines of vaccination 7-Hematologic & polytransfused patients All V. including live vaccine except Steroid Immunosuppressive BMT follow guidelines

  33. 7-Hematologic & polytransfused patients Hemolytic A with splenectomy Sickle disease Penumo Mening Hib early *Pneumo *Mening *Hib 2 w before *Repeated 2-3 y

  34. 7-Hematologic & polytransfused patients ITP Hemophilia No live V. Until inc. platelet stop steroid Compression in deep I.M All polytransfused Hb HA vaccines 3 doses2 doses

  35. 8-Renal diseases Guidelines of vaccination Nephrotic S All obligatory V Varicella Z. Before start Sero-ve family Pneumococcal Influenza V. Hepatitis A Hepatitis B Except Live vaccine Steroid 3M ImmunoS. 6M 2 – 3 y Every year 2 doses 3 doses(double)

  36. Renal failure Except Live vaccine Varicella Z. Before transplant Pneumococcal Influenza V. Hepatitis A Hepatitis B

  37. Guidelines of vaccination 9-Diabetes Mellitus Type I • -All vaccines • Influenza V., • Pneumococcal, • Hib -Hepatitis A , • Varicella Zoster

  38. In Diabetes Not to vaccinate? During acute complications Diabetic ketoacidosis Acute infection Hypoglycemic attacks If previous Guillan Barre Anaphylaxis to chicken eggs. No Influenza V.

  39. 10-Hepatic diseases -All obligatory V. -Except Live V. -Steroid 3M -Immunosuppressive 6M -If infection with hepatitis B, C shouldHA Vaccine

  40. 11-Mentally retarded Cerebral palsy After 1 year Convulsions Under antiepilepticonly DT or Acellular P

  41. Neuro degenerative If steroid postpone MR Chromosomal All V.

  42. 12-HIV Asymptomatic -IPV -DPT -HB -MMR with Ig after exposure -Influenza -Varicella OPV contraindic Symptomatic -IPV -DPT -double ___ ___ ___ OPV contraindic Contacts + + + + + + OPV contraindic

  43. What is instead Chemoprophylaxis INH Amantadine Antiviral Immunoglobulins -Measles -Varicella (VZIG) -Hepatitis B (HBIG) -Rabies (HRIG) -Tetanus (TIG) -Vaccinia (VIG) Growth factorsGCSF GMCSF Interferons

  44. Passive immunisation after measles contact If less than 14 days (most effective if within 72 hours) from contact, give either intramuscular human normal Ig (NIG) or (especially if thrombocytopenic) intravenous Ig (IVIg). The protection lasts approximately 4 weeks. • NIG dose: Under 1 year age 250 mg 1-2 years age 500 mg Over 2 years age 750 mg • IVIg (standard dose) 0.4g/kg

  45. Passive immunisation after varicella zoster contact • High dose oral aciclovir from 7 – 21 days following the initial contact. • Aciclovir dose: Under 2 years age 200 mg four times daily 2-6 years age 400 mg four times daily Over 6 years age 800 mg four times daily • If less than 72 hours from contact, give intramuscular zoster immunoglobulin (ZIG) or (if thrombocytopenic) IVIg. The protection lasts approximately 4 weeks. ZIG dose: Under 5 years age 250 mg 5-10 years age 500 mg Over 10 years age 750 mg • IVIg (standard dose) 0.4g/kg

  46. THANK YOU

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