Immunisation of individuals with underlying medical conditions

Introduction

Some medical conditions increase the risk of complications from infectious diseases, and children and adults with such conditions should be immunised as a matter of priority. These groups may also require additional vaccinations or additional doses of vaccines to provide adequate protection.

Immunosuppression

Individuals with immunosuppression and HIV infection (regardless of CD4 count) should be given inactivated vaccines in accordance with national recommendations. However, these individuals may not mount as good an antibody response as immunocompetent individuals. Therefore, wherever possible, immunisation or boosting of HIV-positive individuals should be either carried out before immunosuppression occurs or deferred until an improvement in immunity has been seen.

Further guidance is provided by the Royal College of Paediatrics and Child Health (RCPCH) (www.rcpch.ac.uk), the British HIV Association (BHIVA) Immunisation guidelines for HIV-infected adults (BHIVA, 2006) and the Childrens HIV Association of UK and Ireland (CHIVA) immunisation guidelines (www.bhiva.org/chiva).

For individuals due to commence immunosuppressive treatments, inactivated vaccines should ideally be administered at least two weeks before commencement. In some cases this will not be possible and therefore vaccination may be carried out at any time and re-immunisation considered after treatment is finished and recovery has occurred. In the case of live vaccines, a longer period before immunosuppression commences may be desirable, but the disadvantages of delaying such treatment are often significant. Specialist advice should be sought from an appropriate physician.

In severely immunosuppressed individuals, re-immunisation should be considered after treatment is finished and/or recovery has occurred. Specialist advice should be sought. Further guidance is provided by the RCPCH (www.rcpch.ac.uk).

Close contacts of immunosuppressed individuals

Some vaccines are contraindicated in immunosuppressed individuals and such individuals may not respond well to other vaccines. Therefore, to minimise the risk of infection, close contacts of immunosuppressed individuals should be fully immunised according to the UK schedule, as a matter of priority. Close contacts of severely immunosuppressed individuals should also be offered vaccination against varicella and influenza. This will reduce the risk of vulnerable individuals being exposed to the serious consequences of vaccine-preventable infections.

Prematurity

It is important that premature infants have their immunisations at the appropriate chronological age, according to the schedule. The occurrence of apnoea following vaccination is especially increased in infants who were born very prematurely.

Very premature infants (born . 28 weeks of gestation) who are in hospital should have respiratory monitoring for 48-72 hrs when given their first immunisation, particularly those with a previous history of respiratory immaturity. If the child has apnoea, bradycardia or desaturations after the first immunisation, the second immunisation should also be given in hospital, with respiratory monitoring for 48-72 hrs (Pfister et al., 2004; Ohlsson et al., 2004; Schulzke et al., 2005; Pourcyrous et al., 2007; Klein et al., 2008).

As the benefit of vaccination is high in this group of infants, vaccination should not be withheld or delayed.

Specific indications for immunisation of other vulnerable groups

Some medical conditions or treatments increase the risk of complications from specific infectious diseases. Individuals who have such conditions or receive such treatments require additional protection, as listed in the appropriate chapters, and so the following vaccines are recommended:

  • Haemodialysis
  • hepatitis B vaccine (see Chapter 18)
  • Haemophilia
  • hepatitis A vaccine (see Chapter 17, including advice on route of administration)
  • hepatitis B vaccine (see Chapter 18, including advice on route of administration)
  • Chronic medical conditions (respiratory, heart, kidney and liver disease and diabetes)
  • influenza vaccine (see Chapter 19)
  • pneumococcal vaccine (see Chapter 25)
  • Immunosuppression
  • influenza vaccine (see Chapter 19)
  • pneumococcal vaccine (see Chapter 25).

    • Additionally, individuals who receive bone marrow transplants are likely to lose any natural or immunisation-derived protective antibodies against most vaccine-preventable diseases. It is unclear whether they may acquire the donorfs immunity, and therefore all individuals should be considered for a re-immunisation programme. Specialist advice should be sought and is available at: www.rcpch.ac.uk/publications/recent_publications/Immunocomp. pdf (for children) and www.ebmt.org/5workingparties/idwp/wparties-id5.html.

    Table 7.1 Immunisation of individuals with asplenia, splenic dysfunction, immunosuppression or complement deficiency

    Suggested schedule for immunisation with conjugate vaccines in individuals with asplenia, splenic dysfunction, immunosuppression or complement deficiency Age at which asplenia, splenic dysfunction or immunosuppression acquired or when complement deficiency diagnosed Vaccination schedule Where possible, vaccination course should ideally be started at least two weeks before surgery or commencement of immunosuppressive treatment. If not possible, see advice in the pneumococcal chapter. Month 0 Month 1 Later First presenting under two years Complete according to national routine childhood schedule including booster doses of Hib/MenC and PCV13. A dose of MenACWY conjugate vaccine should be given at least two months after the Hib/MenC and PCV13 booster doses. After the second birthday, one additional dose of Hib/MenC and a dose of PPV should be given. First presenting over two years and under five years (previously completed routine childhood vaccinations with PCV7) First presenting over two years and under five years (previously completed routine childhood vaccinations with PCV13) Hib/MenC Booster PCV13 Hib/MenC Booster PPV MenACWY conjugate vaccine MenACWY conjugate vaccine First presenting over two and under five years (unvaccinated or previously partially vaccinated with PCV7) Hib/MenC vaccine First dose of PCV13 MenACWY conjugate vaccine PPV (at least two months after PCV13) First presenting over five years (regardless of vaccination history) Hib/MenC vaccine PPV MenACWY conjugate vaccine PCV = pneumococcal conjugate vaccine, PPV = pneumococcal polysaccharide vaccine Data on long-term antibody levels in these groups of patients are limited. Additional doses to cover the higher risks of Hib, meningococcal and pneumococcal disease during childhood, should be considered, depending on the childs underlying condition. Specialist advice may be required

    Other methods of protecting vulnerable individuals

    Immunosuppressed individuals (as above) can be protected against some infections by the administration of passive antibody. After exposure to measles or chickenpox, such individuals should be considered for an injection of the appropriate preparation of immunoglobulin (varicella zoster immunoglobulin (VZIG) or human normal immunoglobulin (HNIG) see varicella and measles, Chapters 35 and 22 respectively). Individuals exposed to chickenpox may benefit from prophylactic acyclovir at a dose of 40mg/kg per day in four divided doses (Kumagai et al., 1999). This may be considered in addition to VZIG or as an alternative when VZIG is not indicated. Treatment with acyclovir should be commenced promptly in this group.

    Prophylaxis with other antibiotic or antiviral drugs may also be indicated in immunosuppressed individuals exposed to infections such as pertussis or influenza. Advice should be sought from the local health protection unit.

    Antibiotic prophylaxis (usually phenoxymethyl penicillin) is advisable for asplenic and hyposplenic patients. Guidelines have been published (Haematology Task Force, 1996) and a patient card and information leaflet are available (details at the end of this chapter).

    Resources

    To obtain copies of the patient card and leaflet Splenectomy, information for patients, contact DH Publications Orderline (Tel: 08701 555 455; e-mail: dh@prolog.uk.com; PO Box 777, London SE1 6XH) or, in Wales, Welsh Assembly Publications Centre (Tel: 029 2082 3683; e-mail: assembly-publications@wales.gsi.gov.uk).

    References

    British HIV Association (2006) Immunisation guidelines for HIV-infected adults. www. bhiva.org/pdf/2006/Immunisation506.pdf. Haematology Task Force (1996) Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. Working Party of the British Committee for Standards in Haematology, Clinical Haematology Task Force. BMJ 17;312(7028): 4304. Klein NP, Massolo ML, Greene J et al. (2008) Risk factors for developing apnea after immunization in the neonatal intensive care unit. Pediatrics 121(3): 463-9. Kumagai T, Kamada M, Igarashi C et al. (1999) Varicella-zoster virus-specific cellular immunity in subjects given acyclovir after household chickenpox exposure. J Infect Dis 180(3): 8347. Lin T-Y, Huang Y-C, Ning H-C and Hsueh C (1997) Oral aciclovir prophylaxis of varicella after intimate contact. Pediatr Infect Dis J 16: 11625. Ohlsson A and Lacy JB (2004) Intravenous immunoglobulin for preventing infection in preterm and/or low-birth-weight infants. Cochrane Database Syst Rev(1): CD000361. Pfister RE, Aeschbach V, Niksic-Stuber V et al. (2004) Safety of DTaP-based combined immunization in very-low-birth-weight premature infants: frequent but mostly benign cardiorespiratory events. J Pediatr 145(1): 58-66. Pourcyrous M, Korones SB, Arheart KL et al. (2007) Primary immunization of premature infants with gestational age <35 weeks: cardiorespiratory complications and C-reactive protein responses associated with administration of single and multiple separate vaccines simultaneously. J Pediatr 151(2): 167-72. Schulzke S, Heininger U, Lucking-Famira M et al. (2005 ) Apnoea and bradycardia in preterm infants following immunisation with pentavalent or hexavalent vaccines. Eur J Pediatr 164(7): 432-5.