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. 2021 Mar 5;180(7):2035–2047. doi: 10.1007/s00431-021-03997-1

Table 1.

Summary of vaccine recommendations in children with chronic illness and/or immunosuppression

Medical condition How is the immune system affected Non-live vaccines recommendation Live-attenuated vaccines recommendation a Additional vaccine(s) recommendation Serological monitoring Guidelines, references
Primary immunodeficiency disorders Genetic abnormality affecting various pathway of the immune response Routine b Permitted in certain situations only

IIV

PCV (± PPSV23)

MCV4

MenB if complement deficiency

“Regularly”, but no guidance on how often

ACIP [29]

Reviews [43, 5154]

Oncological diseases Most cancers and their treatment affect the immune system

Routine during chemotherapy c

Re-start vaccination as of 3m to 6m after completion of chemotherapy (including Hib, regardless of age)

Permitted as of 3m to 6m after completion of chemotherapy

IIV (even during chemotherapy)

PCV (± PPSV23)

MCV

No indication

Could be useful to monitor seroprotection against measles and varicella

CCLG [48]

IDSA [22]

ACIP [29]

AIEOP [55]

Hematopoietic stem-cell transplantation Impaired and immature immune cells, loss of Ig Revaccination starting 3m to 6m after HSCT (including Hib, regardless of age) Revaccination permitted in certain condition as of 1.5y to 2y after HSCT

IIV

PCV, 3d (± PPSV23)

MCV, 2d

No indication

Could be useful to monitor seroprotection against measles and varicella

CCLG [48]

EBMT [49]

IDSA [22]

ACIP [29]

Solid organ transplantation Immunosuppressive treatment Accelerated schedule before SOT. Continue after SOT (as of 2m to 6m post-SOT) Accelerated schedule if > 4w before SOT. Permitted in certain situation after SOT, as of 1y post-SOT [47]

IIV

PCV (± PPSV23)

Frequent monitoring to guide vaccination; it can also inform on protection against measles and varicella

AST, IPTA [47]

IDSA [22]

ACIP [29]

Asplenia/hyposplenia

Sickle cell disease

Higher risk of fulminant infection with encapsulated bacteria and parasite (highest risk in the first 2y of asplenia but persist life-long) Routine, catch-up Hib vaccination regardless of age, HBV vaccination highly recommended if frequent transfusion. Anticipate 2w between vaccination and elective splenectomy Permitted, as of a few days after splenectomy

IIV

PCV (± PPSV23)

MCV4 2d 2m apart, then every 5y

MenB

Frequent monitoring of serotype-specific pneumococcal IgG to guide booster doses

IDSA [22]

ACIP [29]

Human immunodeficiency virus infection Lower CD4+ T-cell Delay vaccination until viral load < 50 copies/mL and CD4 > 15% for 6m. Use high-dose HBV vaccine (40 μg) in adolescents. Give Hib vaccine regardless of age if not immune. DT booster at least 1×/10y. Permitted only if CD4 > 200 cells/μl (or > 15–24% in infants and children) for > 6m

IIV

PCV (± PPSV23)

MCV4 2d 2m apart

Anti-HBs Ig periodically

(if ongoing exposure)

Anti-tetanus, anti-diphtheria 1×/5y

Anti-measles, anti-rubella 1×/3–5y

PENTA [56]

CHIVA

IDSA [22]

ACIP [29]

Immunosuppressive treatment for rheumatologic, renal, neurologic, gastrointestinal conditions Underlying disease with dysregulated immune system, immunosuppressive treatment to control disease activity Accelerate schedule before immunosuppression, but continue during and after Permitted if low immunosuppression

IIV

PCV (± PPSV23)

No indication but monitoring could guide booster doses and inform on protection, in particular against measles and varicella

IDSA [22]

Review [16]

Complement inhibitors (eculizumab) Medication inhibiting the deployment of the terminal complement system, high risk of meningococcal disease Routine Permitted

IIV

PCV

MCV4

MenB

No indication Review [57]
Inflammatory bowel disease Underlying defect in immune system, immunosuppressive treatment Accelerate schedule before immunosuppression, but continue during and after Permitted if low immunosuppression

IIV

PCV (± PPSV23)

No indication, but monitoring could guide booster doses and inform on protection, in particular against measles and varicella

IDSA [22]

Reviews [13, 16]

Nephrotic syndrome Urinary loss of IgG, oedema, immunosuppressive treatment Accelerate schedule before immunosuppression, but continue during and after Permitted if low immunosuppression, VZV vaccine highly recommended

IIV

PCV (± PPSV23)

Monitoring of serotype-specific pneumococcal antibody useful to guide booster. Monitor seroprotection against measles and varicella could be useful as well.

ACIP [29]

Review [18]

Prematurity

Immune cell immaturity

Low IgG level (not had time to transfer from the mother)

Accelerated schedule, based on chronological age Accelerated schedule, based on chronological age

IIV

PCV

MCV

RSV (cf country)

No indication

Review [58]

AAP (RSV) [7]

Diabetes mellitus Impaired phagocytic and neutrophil function, worsen with inadequate glycaemic control Routine, HBV vaccination highly recommended Permitted

IIV

PCV (± PPSV23)

Documentation of protection against HBV. No other indication, antibody response to vaccinations seems to be normal overall

ACIP [29]

Review [59]

CDA (adults) [60]

Renal failure, chronic kidney disease (including dialysis) Mild defects in T cell function, immune response impaired by various factor; Ig loss in dialysate Accelerate schedule before dialysis, but continue during and after, HBV vaccination highly recommended Permitted

IIV

PCV (± PPSV23)

No indication, but monitoring could guide booster doses and inform on protection (vaccine responses likely to be impaired)

ACIP [29]

Review [18]

Chronic liver disease Impaired phagocyte function and defects in opsonising antibody, Ig loss in ascites, hyposplenism (with severe liver disease), higher risk of severe superimposed viral hepatitis Routine, HAV and HBV vaccination highly recommended Permitted

IIV

PCV (± PPSV23)

No indication, but monitoring could guide booster doses and inform on protection ACIP [29]
Chronic heart disease or malformation Infections may precipitate cardiac decompensation Routine Permitted

IIV

PCV (± PPSV23)

RSV (cf country and underlying disease)

No indication

ACIP [29]

AAP (RSV) [7]

Chronic lung disease

Cystic fibrosis

Bronchopulmonary dysplasia

Asthma

Increased risk of severe respiratory infections. Severe lung diseases lead to poor mucociliary clearance, bronchiectasis, defects in pulmonary macrophage function Routine Permitted

IIV

PCV (± PPSV23)

RSV (cf country and underlying disease severity)

No indication

ACIP [29]

AAP (RSV) [7]

Haemophilia Historical increased risk of transfusion-related transmission of viral infection Routine,d HAV and HBV vaccination highly recommended Permitted d No indication, adequate response to HBV vaccine could be documented WFH [61]

Malnutrition

Anorexia nervosa

Immune response impaired due to malnutrition Routine Permitted

IIV?

Insufficient data to date

No indication Review [62]
Obesity Immune response slightly impaired due to overweight (and insulin resistance), higher risk of respiratory infection Routine Permitted IIV No indication, few studies reported lower vaccine responses Reviews [6365]
Coeliac disease Functional hyposplenism (reversible), impaired immune response Routine, HBV vaccination highly recommended Permitted

IIV

PCV (± PPSV23)

± MCV if hyposplenism confirmed

HBV serology (data suggest poor response to HBV vaccine administered prior to gluten-free diet) Review [66, 67]
Chronic neurological disease and neurodevelopmental disorder Decreased protection of airways increases risk of infection, higher risk of complication for some VPD (e.g. influenza, pneumococcus, varicella, pertussis) Routine Permitted, VZV vaccination highly recommended (higher risk of neurological complications)

IIV

PCV

No indication Recent article [68]
Inborn errors of metabolism Neurological defect, concomitant immunodeficiency, metabolic decompensation Routine Permitted

IIV?

PCV?

Insufficient data to date

Unpredictable vaccine responses, depending on underlying immune defect Review [21]

CNS anatomic barrier defect

(e.g. CSF leak, inner ear dysplasia, or cochlear implant)

Deficient anatomical barrier leads to higher risk of CNS infection Routine Permitted PCV (± PPSV23) No indication

IDSA [22]

ACIP [29]

Severe dermatologic conditions (severe eczema, psoriasis) Chickenpox particularly prone to bacterial superinfection; severe dermatologic possibly require immunosuppressive treatment Routine Permitted if low immunosuppression, VZV vaccination highly recommended No indication Review [69]
Parents, close contact of immune compromised individuals ‘Cocooning’ strategy, to decrease the risk to transmit VPD to the immunocompromised children Routine Highly recommended if not immune, OPV and smallpox vaccine are the only LAV contra-indicated in close contact IIV or LAIV Documentation of immunity against measles and varicella if disease/vaccination history uncertain (or immunise regardless)

IDSA [22]

Review [53]

The table summarises the vaccine recommendations available for various health conditions. Recommendations can differ between guidelines and between countries. In some countries, the cost of some vaccines may not be reimbursed. Recommendation for serological monitoring is rarely discussed in guidelines and the ones presented in this table summarise experts’ advices

aThe live-attenuated influenza vaccine should never be given to immune compromised children as they can receive the inactivated influenza vaccine

bEffectiveness doubtful, depend on underlying disease and whether IVIG are given regularly

cPostpone if lymphocyte count < 1.0 × 109/L. Non-live vaccine permitted during chemotherapy but will not be considered as “valid dose”

dReduce the risk of bleeding by subcutaneous injection, use smallest gauge needle and applying pressure and/or ice for 3–5 min after injection

AAP American Academy of Paediatrics, ACIP Advisory Committee on Immunization Practices, AIEOP Italian Association Paediatric Haematology Oncology, CDA Canadian Diabetes Association, CHIVA Children’s HIV Association, CSF cerebrospinal fluid, d dose, DTaP diphtheria-tetanus-pertussis vaccine, EBMT European Society for Blood and Marrow Transplantation, HAV hepatitis A virus, HBV hepatitis B virus, Hib Haemophilus influenzae type b, HSCT hematopoietic stem cell transplantation, IDSA Infectious Disease Society of America, Ig immunoglobulin, IIV inactivated influenza vaccine, IPTA International Paediatric Transplant Association, IPV inactivated poliovirus vaccine, IVIG intravenous immunoglobulins, LAIV live-attenuated influenza vaccine, LAV live-attenuated vaccine, m month, MCV meningococcal conjugated vaccine, MenB meningococcus type B vaccine, MMR measles-mumps-rubella vaccine, NLV non-live vaccine, OPV oral polio vaccine, PCV pneumococcal conjugate vaccine, PPSV23 23-valent pneumococcal polysaccharide vaccine, PENTA Paediatric European Network for Treatment of AIDS, RSV respiratory syncytial virus, SOT solid organ transplantation, VPD vaccine-preventable disease, VZV varicella vaccine, w week, WFH World Federation of Hemophilia, y year