VACCINATION IN

SPECIAL SITUATIONS-
AN OVER-VIEW
DR JAYATI JOSHIPURA
THIRD YEAR PEDIATRIC RESIDENT
GUIDED BY : DR KRUTIKA TANDON, DR RAHUL TANDON
VACCINATION IN IMMUNO-COMPROMISED

• The immunocompromised are in greater need for vaccines as they are more susceptible to
infections.
• However, immunogenicity is lower and risk of adverse effects with live vaccines is higher.
• Ideally, antibody titers should be checked post-immunization on regular basis, and regular
boosters may be administered if needed.
• In severe immunodeficiency, all live vaccines are contraindicated.
• In mild / moderate immunodeficiency, live vaccines may be given if benefits outweigh the
risks.
IAP recommendations for immunization of HIV-infected children
CORTICOSTEROIDS / OTHER IMMUNOSUPPRESSIVE THERAPY

• Children receiving oral corticosteroids in high doses (prednisolone > 2 mg/kg/day or for
those weighing more than 10 kg, 20 mg/day or its equivalent) for > 2 weeks should not
receive live virus vaccines until the steroids have been discontinued for at least one month.
• Killed vaccines are safe but may be less efficacious.
• Children on lesser dose of steroids or those on inhaled or topical therapy may be safely and
effectively given their age appropriate vaccines
• Those on immunosuppressive therapy other than corticosteroids should avoid live vaccines
during therapy unless benefits outweigh risks.
CANCER CASES ON CHEMOTHERAPY/ RADIOTHERAPY

• Patients aged ≥ 6 months with hematological malignancies or solid tumor malignancies

except those receiving anti-B-cell antibodies or intensive chemotherapy, should receive
inactive influenza vaccine (IIV) annually.
• Pneumococcal conjugated vaccine (PCV) should be administered to newly diagnosed
children with hematological or solid malignancies. PPSV23 should be administered
children aged ≥ 2 years at least 8 weeks after PCV.
• Vaccines administered during cancer chemotherapy should not be considered valid doses
unless there is documentation of a protective antibody level.
IMMUNIZATION OF PATIENTS WITH HEMATOPOIETIC STEM CELL
TRANSPLANT (HSCT) IN CHILDREN

• Recipients of HSCT are like the unimmunized as they have lost all memory responses during marrow
ablation.
• Three doses of tetanus/diphtheria-containing vaccine should be administered 6 months after HSCT. For
patients aged ≥ 7 years, a dose of Tdap vaccine may be administered followed by 2 doses of Td vaccine.
•  Three doses of IPV, Hib, hepatitis B vaccine should be administered 6–12 months after HSCT. If a post-
vaccination anti-HBs concentration of ≥ 10 mIU/mL is not attained, hepatitis B vaccine course can be
repeated.
• Three doses of PCV should be administered to children starting at age 3–6 months after HSCT. At 12
months after HSCT, 1 dose of PPSV23 should be given provided the patient does not have chronic
GVHD.
• Live vaccines should not be administered to HSCT patients with active GVHD or ongoing
immunosuppression.
ASPLENIA/HYPOSPLENIA

It may result from sickle cell disease or post splenectomy

• These children are at higher risk of serious infection with encapsulated organisms.
• Vaccination with pneumococcal, Hib, meningococcal and typhoid vaccines is indicated in
addition to all routine vaccines.
• Vaccination should be initiated at least 2 weeks prior to splenectomy for achieving a
superior immunologic response.
• In those who have undergone emergency splenectomy, studies indicate that vaccination
done 2 weeks after splenectomy is associated with a superior functional antibody response.
CONGENITAL IMMUNODEFICIENCIES

• In patients with severe B cell immunodeficiency, live vaccines including OPV, BCG, oral
typhoid, and live attenuated influenza are contraindicated.
• Measles and varicella vaccines may be given but may be ineffective due to concomitant
immunoglobulin therapy.
• Inactivated vaccines may be given but are ineffective.
• In patients with severe T cell immunodeficiencies (SCID) all live vaccines are
contraindicated and all vaccines are ineffective.
• Patients who have received live vaccines especially BCG prior to diagnosis face an increased
risk of complications including disseminated BCG disease.
CHRONIC DISEASES

• Those with chronic neurologic, endocrinologic (diabetes), liver, renal, hematologic, cardiac,
pulmonary and gastrointestinal disease are at increased risk of infections and serious infections.
• Live vaccines may be given safely in these children.
• They should be offered pneumococcal, hepatitis A, varicella, influenza and rotavirus vaccines.
• Important role of hepatitis A vaccine in patients with liver disease
• Pertussis boosting in those with stable neurologic disease.
• Children with severe cardiac and pulmonary diseases should receive pneumococcal and annual
influenza vaccines.
IMMUNIZATION IN CHILDREN WITH HISTORY OF ALLERGY

• First time immunization with any vaccine is contraindicated in children with history of
serious hypersensitivity/ anaphylaxis to any of vaccine components.
• Children with history of serious egg allergy should not receive influenza and yellow fever
vaccines but can safely receive other vaccines including measles and MMR vaccines.
• Those who have had a serious hypersensitivity reaction/ anaphylaxis to a particular
vaccine must never receive it.
• A mild reaction is not a contraindication to vaccination.
• In any case all children should be watched for at least 15 minutes after vaccination for
allergy and resuscitation equipment should be kept standby.
IMMUNIZATION IN RELATION TO ANTIBODY CONTAINING PRODUCTS
RECOMMENDED INTERVALS BETWEEN ADMINISTRATION OF ANTIBODY- CONTAINING
PRODUCTS AND MEASLES- OR VARICELLA-CONTAINING VACCINE, BY PRODUCT
RECOMMENDED INTERVALS BETWEEN ADMINISTRATION OF ANTIBODY- CONTAINING
PRODUCTS AND MEASLES- OR VARICELLA-CONTAINING VACCINE, BY PRODUCT
IMMUNIZATION DURING ILLNESS

• Immunization during acute illness may lead to lower immunogenicity or vaccine

failure. So vaccination should be postponed in a moderate or severe acute illness.
• Vaccination is also postponed to avoid superimposing vaccine reaction on the
underlying illness and to mistakenly attribute a manifestation of underlying
illness to vaccination.
• However, vaccination opportunity should not be missed during minor illnesses
like upper respiratory tract infections, mild diarrhea and otitis media.
IMMUNIZATION OF CHILDREN WITH BLEEDING
DISORDERS OR THOSE RECEIVING ANTICOAGULANTS

• They are at increased risk for bleeding after intramuscular injection.

• When vaccines recommended to be given only by the IM route are to be given, vaccination
can be scheduled shortly after administration of clotting factor replacement.
• A 23 gauge or smaller needle should be used for the vaccination and firm pressure without
rubbing should be applied to the site for at least 5–10 minutes.
• Alternately, vaccines recommended for intramuscular injection could be administered
subcutaneously to persons with a bleeding disorder such as Hib conjugate vaccine, IPV,
pneumococcal polysaccharide vaccine, etc.
IMMUNIZATION IN PRETERM/LOW BIRTH WEIGHT INFANTS

• BCG and birth dose of OPV can be safely and effectively given to low birth weight and preterm babies
after stabilization and preferably at the time of discharge.
• The birth dose of hepatitis B vaccine can be administered at any time after birth in babies weighing > 2
kg.
• All other childhood vaccines may be given as per chronologic age and have acceptable safety,
immunogenicity and efficacy.
• Since preterm and LBW babies may have low muscle mass, the use of needles with lengths of 5/8 inch
or less is appropriate to ensure effective, safe, and deep anterolateral thigh intramuscular administration.
• As they have increased susceptibility to infections, vaccines such as pneumococcal conjugate vaccines,
rotavirus and influenza should be offered if resources permit.
LAPSED IMMUNIZATION/ PREPONED
IMMUNIZATION/ UNKNOWN IMMUNIZATION STATUS

• There is no need to start a vaccine series regardless of the time that has elapsed between
individual doses due to immune memory.
• Doses should not be given 4 or less days from the minimum interval
• If inadvertently given 5 or more days from the minimum interval, the dose should not be
counted.
• In case of unknown immunisation status the child should be considered unimmunized and
vaccinated accordingly.
INTERCHANGEABILITY OF BRANDS

• There is sufficient data that brands of Hib, hepatitis B and hepatitis A may be safely
interchanged with no compromise on immunogenicity and efficacy.
• Vaccination with DTaP should be completed with the same brand
CATCH-UP IMMUNIZATION

• Any number of vaccines live/ inactivated may be given on the same day either singly or as
combination vaccines maintaining a gap of 5 cm between different vaccines.
• Inactivated vaccines can be given at any time in relation to any other live/ inactivated vaccines.
• If not given on the same day, a gap of 4 weeks should be maintained between two live injectable
vaccines, especially MMR and varicella and also yellow fever and live attenuated influenza vaccines.
• However OPV, rotavirus and oral typhoid vaccines may be given at any time in relation to any live/
inactivated vaccine.
• For catch-up immunization, doses should preferably be given at the minimum possible interval to
entail early protection.
IMMUNIZATION FOR TRAVELERS
THANK YOU