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Immunisations and Cardiac Infants

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see National Immunisation Schedule for 2014.

The incidence of vaccine preventable diseases in New Zealand is relatively high1 and some (e.g. pertussis, influenza) pose a significant risk to infants with already impaired cardiac function. It is also known that infants and children in hospital are at risk of missing their routine immunisations because they do not see their general practitioner.10

Routine immunisations on the national schedule should be given to infants with cardiac conditions. In addition, children who have cardiac disease with cyanosis or failure, and children with Down syndrome are eligible for additional pneumococcal vaccines ( PCV13 and 23PPV are funded for high-risk children aged under 5 years). See Ministry of Health Immunisation Handbook 2014 Table 15.3: Children aged under 5 years at high risk of pneumococcal disease (funded). http://immunisation.book.health.govt.nz/15+Pneumococcal+disease/15.5+Recommended+immunisation+schedule#table15.3
Most children with cardiac conditions are also eligible for a free annual influenza vaccination9.

Restrictions, cautions and contra indications

Children with Heterotaxy Syndrome

An individual decision needs to be made for each child. See recommended vaccination schedule for the Asplenic neonate

See Table 1: Recommended immunisation schedule for the asplenic neonate or link to Ministry of Health Handbook 2014: Immunisation of special groups. http://immunisation.book.health.govt.nz/4+Immunisation+of+special+groups

Children with the potential for reduced immune competence (e.g Children with 22 q.11.2 deletion syndrome)

Live vaccines are contraindicated for all individuals with T lymphocyte-mediated immune deficiencies and combined B- and T-lymphocyte disorders.9 However, no parenteral live virus vaccines are given on the Schedule in the first year of life. Rotavirus vaccine is an oral, live, attenuated viral vaccine, which is contraindicated in severe combined immune deficiency (SCID) 9 but is considered safe in milder immune deficiencies. All infants with potential reduced immunecompetence should have their immunological status assessed in consultation with paediatric immunology to determine vaccine safety prior to all live vaccines including Rotavirus and BCG.
http://immunisation.book.health.govt.nz/4+Immunisation+of+special+groups

Children who have received immunoglobulin (eg for myocarditis or Kawasaki disease)

Should not have any parenteral live attenuated viral immunisations(MMR, Varicella) for 11 months post treatment. 8, 9 This does not apply to oral Rotavirus immunisation.

Children who have received ZIG

Should not have any parenteral live attenuated virus immunisations (MMR,varicella) for 5 months post treatment8,9. This does not apply to oral Rotavirus immunisation

Children who have received blood transfusion (including during surgery on bypass)

Should not have any parenteral live attenuated virus immunisations (MMR, varicella) for seven months. This does not apply to oral Rotavirus immunisation.

Children on low-dose aspirin

It has previously been suggested that low dose aspirin be avoided in children following chicken pox or varicella immunisation due to theoretical risk of Reyes syndrome. However, this risk is small compared to the documented risk of shunt thrombosis without low dose aspirin treatment 11,12. The combination of natural varicella infection (chicken pox) and aspirin use in anti-inflammatory (or "high") doses has been associated with Reye's syndrome, but association has not been demonstrated with antiplatelet ("low dose") aspirin treatment13.

We therefore recommend
1. There is no cardiac contraindication to Varicella immunisation in all children once they reach an appropriate age.
2. Low dose Aspirin should be continued in all patients who are taking aspirin to maintain shunt patency

Children on corticosteroids

See NZ Immunisation Handbook - section 4.3: Immune-deficient individuals of all ages Or link to Ministry of Health Immunisation Handbook 2014: http://immunisation.book.health.govt.nz/4+Immunisation+of+special+groups/4.3+Immune-deficient+individuals+of+all+ages

Immunisation around the time of cardiac surgery

Timing and administration of immunisations must allow for a suitable time period before and after cardiac surgery to avoid adding extra stress on these infants during this time period. Routine immunisations should be withheld one week prior to surgery and 4-6 weeks following cardiac surgery. Live vaccines (e.g. MMR) should be withheld for seven months following bypass surgery or any other blood transfusion8,9. This does not apply to Rotavirus, which should follow routine immunisation schedule of 6 weeks, 3 months and 5 months.

Children with Complex Single ventricle or Shunt dependent lesions.

Some infants may have an increased risk of deterioration or collapse following immunisation, as outlined below:

  1. High risk infants
    Infants who have had the Norwood procedure are known to have a significant incidence of interval mortality attributable in part to sudden changes in systemic and pulmonary vascular resistance2. In addition, premature and/or low birth-weight infants prone to pulmonary hypertensive episodes are well documented to develop apnoea, bradycardia and desaturation following immunisations up to 72 hours after administration.  3,4. While there is as yet little clear evidence linking immunisation and deterioration/ collapse in post Norwood infants, concern has been raised which it seems prudent to consider5,6,7.

    Low birth-weight/ premature infants post Norwood procedure and those infants known to have high pulmonary pressures should be considered high risk. Also infants who have had previous reactions to immunisation.
  2. Moderate risk infants
    Other infants post Norwood or with single ventricle physiology can be considered to be at moderate risk of compromise/ desaturation with immunisations.
  3. Low risk infants
    All other infants with cardiac conditions can be considered to have a low risk of compromise following immunisation.

Administration of immunisations

High Risk Infants
Infants considered at 'high risk' of decompensation following immunisations should be admitted to a hospital for 48 - 72 hours observation after immunisation.

Moderate Risk infants
Infants at 'moderate risk' may be given their immunisations in the community; however families should be counselled to observe the child closely for 48 - 72 hours for respiratory distress, cyanosis or general deterioration. If there is deterioration the child should be taken to hospital for review. There should be a low threshold for admission of these infants if there is parental concern.
NB: these families must have direct access to emergency services over this time period (i.e. emergency phone access, transport, reasonable travelling distance to hospital) - if there is concern about ability to access emergency services, admission to hospital over that time should be considered.

Outside these restrictions, routine immunisations can be given routinely in the community.

Prevention and management of decompensation
Common immunisation reactions of fever and irritability in moderate to high risk infants may lead to desaturation, apnoeas and bradycardia. Infants should have access to paracetamol and cooling measures in the event of fever. In the event of desaturation or other signs of decompensation, oxygen saturations, respiratory and heart rate should be monitored and oxygen available.

Managing family risk / advice to family members
In order to reduce the incidence of infection in these infants, the immunisation status of family members (including siblings) in close contact with them should be investigated and vaccination encouraged.

Influenza: Child is eligible for free annual influenza vaccination. Annual influenza vaccination of household contacts should be encouraged but is not funded unless the person has an underlying medical condition.

Pertussis: Ensure siblings are up to date with routine immunisations. Pregnant mothers can get free boostrix (DTap) at 28-38 weeks. Parents and grandparents can get boostrix (DTap boostrix) with the GP (non funded).

Varicella: fragile infants should have varicella vaccine after one year of age. Recommend varicella vaccine for all family members (not funded unless the child is on or likely to go on immune suppressant therapy, or undergo transplant).

  Vaccine
Age Rotavirus Rotavirus Diphth/tet/
pertussis-
containing vaccine
Pneumococcal  vaccines Meningococcal  vaccines Varicella MMR Hib
6 weeks  RV5  DTaP-IPV-HepB/Hib PCV13        
8 weeks       Men CCV (or give with
3 month vaccines)
     
3 months  RV5  DTaP-IPV-HepB/Hib  PCV13         
5 months  RV5  DTaP-IPV-HepB/Hib  PCV13  Men CCV (or 8 weeks
after 1st Men CCV dose)
     
12 months       Men CCV Varicella    
15 months     PCV13      MMR  Hib
2 years     PPV23  MCV4-D      
2 years, 2 months       MCV4-D       
4 years     DTaP-IPV     Varicella   MMR  
5 years       MCV4-D
then 5 yearly 
     
7 years     PPV23         
Annual Influenza vaccine       

No vaccines are contraindicated in asplenia/hyposplenia

Normal type are routine schedule vaccines
Bold type are funded additional vaccines
Italicised type are recommended but not funded vaccines

See Immunisation handbook 2014 section 4.3.4 and table 4.5 for more information and recommendations when asplenia diagnosed at different ages

References

  1. Grant CC, Roberts M, Scragg R, Stewart J, Lennon D, Kivell D, Ford R, Menzies R. Delayed immunization and risk of pertussis in infants: unmatched case-control study. BMJ 2003;326:852-53.
  2. Wright GE, Crowley DC, Charpie JR, Ohye RG, Bove EL, Kulik TJ. High systemic vascular resistance and sudden cardiovascular collapse in recovering Norwood patients. Ann Thorac Surg 2004;77:48-52.
  3. Lee J, Robinson JL, Spady DW. Frequency of apnea, bradycardia, and desaturations following first diphtheria-tetanus-pertussis-inactivated polio-Haemophilus influenzae type B immunization in hospitalized preterm infants. BMC Pediatr. 2006;6:20.
  4. Pfister RE, Aeschbach V, Niksic-Stuber V, Martin BC, Siegrist CA. Safety of DTaP-based combined immunization in very-low-birth-weight premature infants: frequent but mostly benign cardiorespiratory events. J Pediatr 2004;145:58-66.
  5. Davidson A, Marks LA. Shots and shunts. Pediatr Cardiol 1996;17:132-3.
  6. Bartram U, Grünenfelder J, Van Praagh R. Causes of death after the modified Norwood procedure: a study of 122 postmortem cases. Ann Thorac Surg1997;64:1795-802.
  7. McAlvin B, Clabby ML, Kirshbom PM, Kanter KR, Kogon BE, Mahle WT. Routine immunizations and adverse events in infants with single-ventricle physiology. Ann Thorac Surg 2007;84:1316-19.
  8. American Academy of Paediatrics, In Pickering LK, BakerCJ, LongSS, McMillanJA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th Ed. Elk Grove Village, American Academy of Paediatrics; 2006.
  9. Ministry of Health 2014, Immunisation Handbook. Ministry of Health. Wellington, New Zealand  http://immunisation.book.health.govt.nz
  10. Ginsberg C, Andrews W. Orthotopic hepatic transplantation for unimmunized children: a paradox of contemporary medical care. Ped I D J 1987;6:264-5Li JS, et al. Clinical outcomes of palliative surgery including a systemic-to-pulmonary artery shunt in infants with cyanotic congenital heart disease: Does aspirin make a difference? Circulation. 2007; 116: 293-7
  11. Li JS, et al. Clinical outcomes of palliative surgery including a systemic-to-pulmonary artery shunt in infants with cyanotic congenital heart disease: Does aspirin make a difference? Circulation. 2007; 116: 293-7
  12. Heidari-Bateni G, et al. Defining the best practice patterns for the neonatal systemic-to-pulmonary artery shunt procedure. J Thorac Cariovasc Surg 2014; 147: 869-73
  13. Schror K. Aspirin and Reye syndrome: a review of the evidence. Pediatr Drugs 2007; 9(3): 195-204

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Document Control

  • Date last published: 02 February 2015
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Cardiology
  • Author(s): Elizabeth Wilson, Kirsten Finucane, Marion Hamer, Heather Spinetto
  • Editor: Marion Hamer
  • Review frequency: 2 years