Immunizing the Immunocompromised. Leilani T. Sanchez, MD, DPPS, DPIDSP Crowne Plaza Galleria Manila, 21 February 2013

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1 Immunizing the Immunocompromised Leilani T. Sanchez, MD, DPPS, DPIDSP Crowne Plaza Galleria Manila, 21 February 2013

2 WHO World Health Statistics Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

3 Ten (10) Leading Causes of Child Mortality No. & Rate / 100,000 population 3 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

4 Ten (10) Leading Causes of Child Mortality No. & Rate / 100,000 population 4 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

Objectives To present the current recommendations and evidence in the immunization of immunocompromised pediatric patients To discuss the risks, benefits, and timing of vaccination in the setting of

5 Objectives To present the current recommendations and evidence in the immunization of immunocompromised pediatric patients To discuss the risks, benefits, and timing of vaccination in the setting of immunosuppression To highlight the management considerations and prospective immunization strategies for particular special risk groups 5 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

Antimetabolites Radiation Corticosteroids 6

6 Immunosuppression Disease Primary immunodeficiency Secondary immunodeficiency - Leukemia or Lymphoma - Generalized malignancy Chemotherapy Alkylating agents Antimetabolites Radiation Corticosteroids 6 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

Challenges of Vaccinating Immunocompromised Children Safety issues Immunogenicity Decreased vaccine efficacy Changing immune status Heterogeneous patient groups with variable immune deficits

7 Challenges of Vaccinating Immunocompromised Children Safety issues Immunogenicity Decreased vaccine efficacy Changing immune status Heterogeneous patient groups with variable immune deficits Increasing use of potent immunosuppressive regimens Preimmunosuppression immunization Vaccination of contacts to reduce exposure of the immunocompromised child Compliance Nield LS, Troish MJ, Kamat D. Vaccinating the immunocompromised child. Consultants for Pediatricians.2009;8(Suppl):S7-S14 7 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

8 The 10 Commandments for Immunizing the Immunocompromised 8 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

9 The Ten Commandments of Immunizing the Immunocompromised I Thou shall not give live vaccines to severely immunocompromised patients Live vaccines can cause severe or fatal reactions in immunocompromised patients due to uncontrolled replication of the vaccine virus. Live vaccines can be given to children with isolated immunoglobulin A deficiency. Attenuated live-virus vaccine can be given to children with complement deficiencies and disorders of phagocyte function. 9 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

10 Severely Immunocompromised Patients Active leukemia, lymphoma, generalized malignancy, aplastic anemia, graft-versus-host disease, or congenital immunodeficiency HIV-infected persons with CD4 cell counts < 200/mm 3, history of AIDS-defining illness, or clinical manifestations of symptomatic HIV Recent radiation therapy Solid-organ or bone marrow transplants, within 2 years of transplantation Transplant recipients still taking immunosuppressive drugs 10 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

Severely Immunocompromised Patients High-dose corticosteroids Alkylating agents (such as cyclophosphamide) Antimetabolites (such as azathioprine, 6-mercaptopurine) Transplant-related

11 Severely Immunocompromised Patients High-dose corticosteroids Alkylating agents (such as cyclophosphamide) Antimetabolites (such as azathioprine, 6-mercaptopurine) Transplant-related immunosuppressive drugs (such as cyclosporine, tacrolimus, sirolimus, mycophenolate mofetil, and mitoxantrone) Cancer chemotherapeutic agents ( excluding tamoxifen but including low-dose methotrexate weekly regimens) TNF blockers (such as etanercept, rituximab, adalimumab, and infliximab) 11 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

12 The Ten Commandments of Immunizing the Immunocompromised II Thou shall give inactivated vaccines to immunocompromised patients Immune responses to inactivated vaccines may be inadequate. All children 6 months of age or older and adolescents with primary or secondary immunodeficiencies should receive an annual ageappropriate inactivated influenza vaccine 12 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

13 The Ten Commandments of Immunizing the Immunocompromised III Thou shall vaccinate household contacts of immunocompromised patients The following live vaccines may be given: MMR Varicella Rotavirus LAIV Immunocompetent siblings and other household contacts should not receive OPV 13 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

14 The Ten Commandments of Immunizing the Immunocompromised IV Thou shall give vaccines only after chemotherapy has been discontinued Inactivated or recombinant vaccines may be administered 3 months after the end of chemotherapy Live vaccines are deferred until 6 months after chemotherapy 14 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

15 15 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

16 The Ten Commandments of Immunizing the Immunocompromised V Thou shall not give live vaccines to patients receiving large doses of corticosteroids 2mg/kg per day of prednisone or equivalent 20mg/day for children who weigh >10 kg Given for 14 days or longer Live vaccines can be given only after corticosteroid therapy has been discontinued for at least 1 month. 16 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

17 The Ten Commandments of Immunizing the Immunocompromised Cytokine inhibitors VI Thou shall not give live vaccines to patients receiving treatment of biologic response modifiers TNF α inhibitors are the prototype agents (adalimumab, certolizumab, etanercept, golimumab, infliximab) Live vaccines can be given only after therapy has been discontinued for at least 1 month. 17 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013 Administer all live vaccines a minimum of 1 month before initiation of therapy.

18 The Ten Commandments of Immunizing the Immunocompromised VII Thou shall revaccinate hematopoietic cell transplant (HCT) recipients Antibody titers to vaccine preventable diseases decline during the 1-4 years after HCT. HCT recipients should be routinely revaccinated after HCT, regardless of the source of the transplanted cells. Transplant recipients should receive all recommended immunizations, preferably prior to transplantation. 18 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

19 Revaccination of HCT recipients Inactivated vaccines Revaccination with inactivated vaccines should begin 6 months after HCT. Live attenuated vaccines MMR and varicella vaccines should be administered 24 months after transplantation if the HCT recipient is presumed to be immunocompetent. 19 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

20 Vaccination Schedule After Allogenic Hematopoietic Stem Cell Transplant for Children and Adolescents Inactivated vaccines Live attenuated vaccines 20 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

21 The Ten Commandments of Immunizing the Immunocompromised VIII Thou shall vaccinate solid organ transplant recipients before transplantation Children and adolescents being considered for solid organ transplantation should receive immunizations recommended for their age at least 2 weeks before the transplantation is performed. Live-virus vaccines should be given at least 1 month before transplantation. 21 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

Vaccination of Solid Organ Transplant Recipients after transplantation After solid organ transplantation, DtaP, Hib, Hepatitis B, Hepatitis A, inactivated influenza, and pneumococcal and

22 Vaccination of Solid Organ Transplant Recipients after transplantation After solid organ transplantation, DtaP, Hib, Hepatitis B, Hepatitis A, inactivated influenza, and pneumococcal and meningococcal conjugate and polysaccharide vaccines can be administered. Most experts recommend at least 6 months after transplantation, when immune suppression is less intense, for resumption of immunization schedules. There are no general recommendations on the use of live virus vaccines in this population. 22 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

23 The Ten Commandments of Immunizing the Immunocompromised IX Thou shall vaccinate children with asplenia or functional asplenia When surgical splenectomy is planned, immunization status for Hib, pneumococcus, and meningococcus should be ascertained, and needed vaccines should be administered at least 2 weeks before surgery, if possible. 23 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013 If splenectomy is emergent, administration of indicated vaccines is recommended 2 weeks after surgery.

24 The Ten Commandments of Immunizing the Immunocompromised X The risk of adverse events in these children following immunization is low. Thou shall not be scared to vaccinate immunocompromised patients 24 Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

25 Basic Principles of Vaccinating Immunocompromised Children Determine immune status Carefully assess risks versus benefits Understand that inactivated vaccines are generally safe and play an important role and that live vaccines are generally contraindicated, except in select circumstances Vaccinate contacts and healthcare workers Follow current vaccine recommendations Administer vaccines before immunosuppression when possible Consider antibody testing to evaluate vaccine response Pickering LK, Baker CJ, Freed GL, et al; Infectious Disease Society of America. Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the Infectious Disease Society of America. Clin Infect. Dis.2009 Sep 15;49(6): Erratum in Clin. Infect. Dis Nov 1;49(9): Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

27 References Miller MA, Rathore MH. Immunization in Special Populations. Advances in Pediatrics (59): Shetty AK, Winter MA. Immunization of Children Receiving Immunosuppressive Therapy for Cancer or Hematopoietic Stem Cell Transplantation. The Ochsner Journal 2012 (12): Crawford NW, Bines JE, Royle J, Buttery JP. Optimizing immunization in pediatric special risk groups. Expert Rev. Vaccines 2011 (10): American Academy of Pediatrics. Immunocompromised children. In: American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. Pickering LK, ed. 29 th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012: Centers for Disease Control and Prevention. General Recommendations on Immunization. In: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, eds. 12th ed., second printing. Washington DC: Public Health Foundation, 2012: Centers for Disease Control and Prevention. Immunocompromised travelers. In:Centers for Disease Control and Prevention. CDC Health Information for International Travel New York: Oxford University Press; Immunizing the Immunocompromised Leilani T. Sanchez 21 February 2013

CLINICAL GUIDELINES. Summary of Literature and Recommendations Concerning Immunization and Steroid Injections Thomas J. Gilbert M.D., M.P.P.

CLINICAL GUIDELINES. Summary of Literature and Recommendations Concerning Immunization and Steroid Injections Thomas J. Gilbert M.D., M.P.P. CLINICAL GUIDELINES Summary of Literature and Recommendations Concerning Immunization and Steroid Injections Thomas J. Gilbert M.D., M.P.P. 11/2/15 Several practices routinely delay steroid injections