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Vaccination in Preterms by Dr Padmesh V

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Vaccination in Preterms and Low birth weight babies
(Based on recommendations from AAP, CDC, The Redbook, IAP)

Publié dans : Santé & Médecine
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Vaccination in Preterms by Dr Padmesh V

  1. 1. Immunization in Preterm and Low Birth Weight Infants Dr Padmesh V DNB(Ped), DM(Neonatology)
  2. 2. • INTRODUCTION: • Preterm infants are at increased risk of infections with increased incidence and severity. • Vaccination is often delayed in preterm infants due to – Lack of knowledge about safety and effectiveness of vaccines in preterm infants among healthcare workers and parents. – Fear or adverse events, as an increase in cardiorespiratory events following immunization in the very preterm is reported. • Accordingly, several recommendations were made to closely observe hospitalized extremely-low-birth-weight infants for significant adverse events for up to 72 hours.
  3. 3. • Causes for decreased immunity in preterms: • Decreased keratinization of skin (initial barrier against infection). Stratum corneum develops fully between weeks 32 and 34 of gestation and matures rapidly within 2 weeks of delivery. • Gastric acidity, another nonspecific means of immune defense, is decreased. • Decreased secretory IgA production until week 29 of gestation. • Decreased complement activity, decreased neutrophil stores, and neutrophil adhesion.
  4. 4. • Causes for decreased immunity in preterms: • Reduced ability of CD4+ lymphocytes to stimulate humoral immunity. • Decreased activity by cytotoxic CD8 T cells. • Passive immunity, rendered by maternal transfer of IgG to the fetus via pinocytosis, occurs primarily in the last trimester of development. • Favorable intestinal micobiota derived from maternal human or donormilk may be deprived in preterms who are on IV Fluids alone.
  5. 5. • Deficits in virtually all aspects of the immune system render premature infants vulnerable to nosocomial and vaccine-preventable infections. • In general, generation of the antibody response after vaccination directly correlates with chronologic age, gestational age, and birthweight. • Immunocompetence in newborns depends on prenatal maturation as each additional week of gestation sees an increased response to antigens. • Postnatal maturation, which begins upon exposure to environmental antigens, occurs in preterm infants at a speed comparable to that of full-term infants.
  6. 6. • Although studies have shown decreased immune responses to several vaccines administered to VLBW babies and extreme preterms, most of them, including infants who receive dexamethasone for chronic lung disease, produce sufficient vaccine-induced immunity to prevent disease. (Sufficient, although decreased) • Vaccine dosages administered to term infants should not be reduced or divided when given to preterm or low birth weight infants.
  7. 7. • ADVERSE EFFECTS IN PRETERM VACCINATIONS: • Some studies show that cardiorespiratory events may increase in ELBW/VLBW who receive selected vaccines. • Risk factors for post-immunization apnea: – Apnea within 24 hours prior to immunization – Younger age – Weight <2000 g at the time of immunization – History of apnea during previous vaccination – Very sick at birth • It may be prudent to monitor infants with these characteristics for 48 hours after immunization if they are still in the hospital.
  8. 8. • RECOMMENDATIONS: • Medically stable preterm infants who remain in the hospital at 2 months of chronologic age should receive all inactivated vaccines recommended at that age. [A medically stable infant is defined as one who does not require ongoing management for serious infection; metabolic disease; or acute renal, cardiovascular, neurologic, or respiratory tract illness and who demonstrates a clinical course of sustained recovery and a pattern of steady growth. ] • All immunizations required at 2 months of age can be administered simultaneously to preterm or low birth weight infants, except for oral rotavirus vaccine, which should be deferred until the infant is being discharged from the hospital to prevent the potential health care-associated spread of this live vaccine virus.
  9. 9. • RECOMMENDATIONS: • The number of injections of other vaccines at 2 months of age can be minimized by using combination vaccines. • When it is difficult to administer 3 or 4 injections simultaneously to hospitalized preterm infants because of limited injection sites, the vaccines recommended at 2 months of age can be administered at different times. To avoid superimposing local reactions, 2-week intervals may be reasonable. [Redbook 2018] • The choice of needle lengths used for IM vaccine administration is determined by available muscle mass of the preterm.
  10. 10. • RECOMMENDATIONS: Preterm/LBW Immunizations Regular vaccines Special considerations 1. BCG 1. Influenza 2. Polio 2. Palivizumab 3. Hepatitis B 4. DTaP 5. Hib 6. Rotavirus 7. Pneumococcal
  11. 11. • INDIVIDUAL VACCINES: • BCG: • There are various recommendations regarding the timing of BCG in preterms/LBW. • Some guidelines recommend BCG to be given at 34 weeks corrected GA. • IAP recommends administering BCG to stable preterms at the time of discharge. • Safety and Immunogenicity of Early Bacillus Calmette-Guérin Vaccination in Infants Who Are Preterm and/or Have Low Birth Weights-A Systematic Review and Meta-analysis (Nov 2018) recommends early (within 7 days of birth) vaccination in stable preterms and LBW.
  12. 12. • INDIVIDUAL VACCINES: • Polio: • IAP recommends that birth dose of OPV can be effectively given to low birth weight and preterm babies after stabilization and preferably at the time of discharge. • IPV or combination vaccination should be used on a regular schedule as per chronological age.
  13. 13. • INDIVIDUAL VACCINES: • HEPATITIS B: • In <2kg babies: If mother is HBsAg Negative, delay first dose of hepatitis B vaccine until 1 month of age or hospital discharge, whichever is earlier. (Redbook,2018) • In babies <2 kg born to a hepatitis B positive mother, hepatitis B vaccine should be given along with HBIG within 12 hours of birth (this dose is not counted as part of primary series) and 3 more doses at 1, 2 and 6 months are recommended. • Hepatitis B vaccine is the only vaccine known to have a significantly lower response in preterms compared to full term infants (45%-85% vs 90%- 100% when given at birth). Hence to ensure maximum protection, we delay giving it until 1 month or at discharge whichever is earlier.
  14. 14. • INDIVIDUAL VACCINES: • DTaP: • The immune response to the acellular pertussis vaccine components in preterm infants has been shown to be lower than in those born at full term, but still expected to be higher than that required for protection. • DTaP can be given according to the chronological age in preterms. • Acellular vaccines have fewer side effects than whole-cell vaccines.
  15. 15. • INDIVIDUAL VACCINES: • Tdap for care givers: • Preterm infants who haven't completed the primary series are at increased risk of pertussis infection and pertussis related complications. • Therefore tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine should be administered to all pregnant women (optimally, early in the interval between weeks 27 and 36 of gestation, to yield high antibody levels in the infant) during every pregnancy. • Tdap should be administered immediately postpartum for women who never have received a previous dose of Tdap.
  16. 16. • INDIVIDUAL VACCINES: • Rotavirus vaccine: • Oral rotavirus vaccine should be deferred until the infant is being discharged from the hospital to prevent the potential health care- associated spread of this live vaccine virus. • The first dose of rotavirus vaccine should be administered from 6 weeks through 14 weeks+6 days of age (the maximum age for the first dose is 14 weeks+6 days). • All doses of rotavirus vaccine should be administered by 8 months, 0 days of age.
  17. 17. • INDIVIDUAL VACCINES: • Pneumococcal vaccine: • Preterms may show lower antibody levels to pneumococcal vaccine after a primary dose but are adequate for protection. • The booster dose is strongly advised in preterms to help maintain protection. • Both the 10-valent (PCV10/Synflorix) and 13-valent pneumococcal conjugate (PCV13/Prevenar 13) vaccines have been shown to be immunogenic in preterms. • Administer these vaccines as per chronological age.
  18. 18. • INDIVIDUAL VACCINES: • Hemophilus Influenza b vaccine: • Even though premature infants develop lower antibody concentrations than term infants following Hib conjugate vaccination, the antibody level is sufficient to confer a high level of protection to premature babies. • Hib vaccines should be administered according to chronological age.
  19. 19. • INDIVIDUAL VACCINES: • Influenza virus: • Because all preterm infants are considered at increased risk of complications of influenza, 2 doses of inactivated influenza vaccine, administered 1 month apart, should be offered for all preterm infants beginning at 6 months of chronologic age. • No effective vaccine is available for infants <6 months, so the focus should be on maternal and caregiver immunization. It is very important that household contacts, child care providers, and hospital nursery personnel caring for preterm infants receive influenza vaccine annually. • Once the infant is age 6 months, the vaccine should be given to the preterm too regardless of maternal immunization.
  20. 20. • INDIVIDUAL VACCINES IN PRETERMS / LBW: VACCINE WHEN GIVEN BCG At time of discharge Polio At time of discharge Hepatitis B (Mother negative) At time of discharge, or 1 month age whichever is earlier Hepatitis B (Mother Positive) Within 12 hours of birth. (Do not count as part of series) DTaP Chronological age Rotavirus On discharge Hib Chronological age Pneumococcal Chronological age Influenza Chronological age
  21. 21. • INDIVIDUAL IMMUNOPROPHYLAXIS: • Palivizumab • Humanized monoclonal antibody against the RSV F glycoprotein. • For prevention of serious RSV lower respiratory tract disease in children at high risk of RSV disease. • Palivizumab does not interfere with response to routine immunization with live virus vaccines (eg, measles, mumps, rubella, varicella). • Preterm infants born before 29 weeks gestation; infants born with certain congenital heart defects; and certain infants with chronic lung disease of prematurity or hemodynamically significant heart disease may benefit from monthly immunoprophylaxis with palivizumab.
  22. 22. • Targeted immunisation or cocooning • Most infants acquire diseases such as whooping cough and influenza from family members. • “Cocooning” or “targeted immunisation” involves ensuring siblings are up to date with their immunisations, and immunising the infant’s close contacts (parents, grandparents and care givers) to reduce the risk of disease exposure for the infant. • Important vaccines to consider include pertussis- containing vaccines and influenza vaccines.
  23. 23. • REFERENCES:
  24. 24. THANK YOU!

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