30 Vaccinations for Pediatric Patients with Cardiac Disease
Theoretically, the current vaccination schedule of the German Vaccination Committee (STIKO) also applies to children with congenital heart defects. The current recommendations are available on the Internet (www.rki.de). National vaccination guidelines should be applied according to local standards for each country.
However, some special aspects should be observed for children with heart disease and these are discussed briefly below. For detailed recommendations, the reader is referred to the official STIKO publications and the respective Summary of Product Characteristics.
Passive immunization with palivizumab is recommended for children under age 2 years with a hemodynamic heart defect at the beginning of the respiratory syncytial virus (RSV) season (dosage: 15 mg/kg every 4 weeks during the RSV season). The RSV season begins between October and December and ends between March and May in the Northern Hemisphere.
For children, adolescents, and adults with chronic cardiovascular disease, the STIKO recommends an annual flu shot, optimally between September and November. Vaccination is approved over age 6 months.
Patients who take phenprocoumon or warfarin should not have intramuscular injections due to the risk of muscular bleeding. The vaccine is usually injected subcutaneously in this case.
For patients with congenital asplenia (e.g., in a heterotaxy syndrome), vaccinations against pneumococci, meningococci, and Haemophilus influenzae type b (Hib) are particularly important.
The Hib vaccination is given according to the regular vaccination schedule. For the pneumococci immunization, the usual procedure of general basic immunization applies (three basic vaccinations with the pneumococcal conjugate vaccine in the first year of life and booster in the second year). At the age of 2 to 5 years, the children are given another supplementary vaccination with pneumococcal conjugate vaccine. After age 5 they are then given the polysaccharide vaccine. Other boosters may be considered—for children under age 10 at intervals of at least 3 years and for adults at intervals of 5 years. There may be pronounced reactions to the vaccination, however, so a risk–benefit assessment must be made on a on a case-by-case basis (e.g., taking the current vaccine titer into consideration).
In addition, all patients under age 2 years should also be vaccinated with the conjugated meningococcal C vaccine. Afterward, supplementary immunization with the meningococcal polysaccharide vaccine against serotypes A, C, W135, and Y is recommended at an interval of 6 to 12 months after reaching age 2 years. It should be noted that most meningococcal infections in Germany, Austria, and Switzerland are caused by serotype B, for which there is no approved vaccine yet.
The DiGeorge syndrome is common in patients with conotruncal heart defects such as tetralogy of Fallot, truncus arteriosus communis, or pulmonary atresia. The range of immune deficiency due to hypoplasia or aplasia of the thymus in patients with a DiGeorge syndrome is wide. It extends from patients that have no T cell abnormalities to patients with a low T cell count but largely normal T cell function (partial DiGeorge syndrome) to patients who have almost no T cells, (complete DiGeorge syndrome). The respective immunological examinations should always be ordered if there is a suspicion of a DiGeorge syndrome.
For inactivated vaccines, the regular vaccination schedule applies to DiGeorge patients. The annual flu shot is also recommended. The success of the vaccination should be checked by monitoring the titer. Before vaccinating with live vaccines, a basic immunological examination is recommended. Live vaccinations should be given only after consultation with an immunologist. In addition, RSV prophylaxis is recommended for the winter months. Varicella immunoglobulin is indicated for patients exposed to chickenpox.
Before and after cardiac surgery
For elective surgery, a minimum waiting period of 3 days should be maintained after immunization with inactivated vaccines and a minimum period of 14 days after live vaccines. This makes it possible to distinguish between possible reactions to immunization and complications of surgery. These minimum waiting periods also apply to vaccinations given after surgery. For urgent or vital indications, however, neither vaccination nor surgery should be postponed.
Immunoglobulins, which are also components of fresh frozen plasma, block the proliferation of live vaccine viruses. For this reason, an interval of 3 months between administration of immunoglobulin products and vaccination with live vaccines is recommended.
To reduce the risk of a hepatitis B infection through transfusions, the hepatitis B immunization should be completed before cardiac surgery if possible.
Before a heart transplant, basic immunization should be completed if possible. It may be recommended to give the vaccinations as soon as possible—ahead of the normal vaccination schedule (e.g., starting hepatitis B in the neonatal period; MMR and varicella after 9 months; diphtheria, pertussis, tetanus, polio, Hib as early as 6 weeks). An annual flu shot is also recommended for transplant patients.
After transplantation, live vaccines are contraindicated under immunosuppression treatment (exceptions must be cleared with the immunologist on a case-by-case basis). Under high-dose steroids, it should be noted that an adequate antibody titer is not reached after vaccinations. The success of the vaccination should be checked by determining the titer for patients undergoing immunosuppression treatment.