Immunisation guideline for children with chronic kidney disease

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Objectives

  1. State the vaccines required for all children with Nephrotic Syndrome (NS) and Chronic Kidney Disease (CKD).
  2. State the vaccines required for all children for whom a renal transplant is planned.
  3. Provide information on vaccinations that can be given to immunocompromised children.
  4. Provide an accurate and up to date vaccine record for all children with CKD or a renal transplant.

Clinical questions answered by the guideline:

  1. Which vaccines do children with CKD require?
  2. Which vaccines do children who are to receive a renal transplant require?
  3. Which vaccines can be given to immunocompromised children?
  4. Where will vaccine information be documented?

Scope

For use across the Scottish Paediatric Renal & Urology Network. 

Audience

This document provides information on the immunisations necessary for children with chronic kidney disease (CKD) including those requiring a renal transplant, and those with Nephrotic Syndrome.

It is intended for use by all health professionals (for example doctors, nurses and pharmacists) who look after children with renal conditions within Scotland. It is to be used in conjunction with the Green Book ‘Immunisation against infectious disease’ 2014 online edition (1) and updated online chapters available in publication on the Department of Health (DoH) website  https://www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book

This guideline is based on vaccination guidance provided by the DoH (1) and the Paediatric Nephrology Handbook (2).

Routine Childhood Immunisation Programme

All children in Scotland, including those with CKD, should receive routine childhood immunisations. The routine childhood immunisation programme is reviewed regularly by the DoH, and can be accessed on the website: www.immunisationscotland.org.uk (3) 

 

Vaccination of Individuals with Uncertain or Incomplete Immunisation Status

If an immunisation course is interrupted, it should be resumed and completed as soon as possible. The course of immunisations should not be “started again” (4).

A full vaccine history is essential for all children who attend the renal unit. Every effort must be made to clarify which vaccines the child has received. Useful information may be found in the parent-held child health record, and through the child’s General Practitioner.

There is an algorithm available:

https://www.gov.uk/government/publications/vaccination-of-individualswith-uncertain-or-incomplete-immunisation-status

Vaccinations for Children Approaching Dialysis & Transplantation

All pre-renal transplant children will have their infectious disease and immunisation status established and will be initially screened for:

  • VZV (Varicella Zoster Virus)
  • Hepatitis B (Part of the routine childhood immunisation programme for babies born on or after 1st August 2017) (3)
  • Hepatitis C
  • CMV (Cytomegalovirus)
  • EBV (Epstein Barr Virus)

Titres should be repeated every six months, unless IgG positive.

All children with CKD should receive all routine childhood vaccinations. This should be documented with their transplant work up record. (see Appendix I).

Children who are being worked up for renal transplantation also require:

  • Varicella
  • BCG
  • Hepatitis B (Part of the routine childhood immunisation programme for babies born on or after 1st August 2017) (3)
  • Pneumoccocal (every 5 years) (5)
  • Inactivated Influenza Injection (yearly) (6)
Vaccinations Required in Nephrotic Syndrome

All children with NS should receive all routine childhood vaccinations. The timing of these may be interrupted if the child is treated with high dose steroids or immunosuppressant therapies; see Appendix II for a list of vaccines that can be given safely. Vaccinations should be documented for each child. (see Appendix III).

Other vaccines required include:

  • Varicella
  • Pneumoccocal (every 5 years) (5)
  • Inactivated Influenza Injection (yearly) (6)
Administration of more than one Live Vaccine

For many years the recommendation from Immunisation against Infectious Diseases (the Green Book)(1) that when two live vaccines were to be given to the same person then the live vaccines should be given on the same day or separated by an interval of at least four weeks. This guidance has now changed and the timing should not be generalised to all live vaccines. The interval should be based upon specific evidence for each vaccine(7).  (see Appendix IV)

Vaccines

BCG

Bacillus Calmette-Guerin (BCG) is a live vaccine against tuberculosis (8). It should not be given to immunocompromised individuals (see section 8).

All pre-transplant patients require a mantoux test to check their BCG status.  Patients with a negative mantoux will require the BCG vaccine. Tuberculin testing should not be carried out within 4 weeks of receiving a MMR vaccine as the response may be a falsely negative. If the mantoux test has already been initiated, then MMR should be delayed until it has been read unless protection against measles is urgent. (see Appendix IV)

Dosage schedule for BCG vaccine by intradermal injection:

Age < 12 months – a single dose 0.05ml 

Age ≥ 12 months - single dose 0.1ml

No further immunisations should be given in the arm used for BCG for at least three months, due to risk of regional lymphadenitis.

Patients cannot be listed on the Transplant List for at least 3 month following BCG vaccine (2).

NB for patients treated at the Royal Hospital for Children in Glasgow, the mantoux +/- BCG are performed in ward 1C. At present this can be requested on Trakcare.  

Hepatitis B  

(NB Different manufacturer products are NOT interchangeable)

Hepatitis B containing vaccines are inactivated (not live): they do not contain live organisms and cannot cause the diseases against which they protect.

All children born on or after 1 August 2017 will have received hepatitis B as part of the routine childhood immunisation programme (3), therefore children born after this date who require haemodialysis, peritoneal dialysis and renal transplantation will require annual antibody levels. If they fall below 100iu/L a booster dose should be given to patients who have previously responded to the vaccine (2 & 9).

All pre-dialysis, dialysis and pre-transplant children born up to and including 31 July 2017 will be vaccinated against hepatitis B. (9)

Dosage schedule by Intramuscular* injection pre-dialysis and pretransplant

Age 

Vaccine

Dose

1month – 15years

Engerix B®

10micrograms  given at month 0, 1, 2

(accelerated schedule). 

Booster dose at 6-12 months. (2)

16 – 18years

 

 

Engerix B®

 

 

20micrograms  given at month 0, 1, 2 

(accelerated schedule).

Booster dose at 6-12 months. (2)


Dosage schedule by Intramuscular* injection for children on Haemodialysis and Peritoneal Dialysis:

Age 

Vaccine

Dose

1month – 15years

Engerix B®

10micrograms  given at month 0, 1, 2 and 6 (accelerated schedule) (2).

16 – 18years

Engerix B®

40micrograms  given at month 0, 1, 2 and 6 (accelerated schedule)(2).


An Anti-HBs antibody titre above 100iu/L 8 weeks after completion of the vaccination course indicates an adequate response (10). 

Antibody levels in dialysis patients should be monitored annually. If they fall below 100iu/L a booster dose should be given to patients who have previously responded to the vaccine (2 & 9).

*Deltoid muscle is preferred in older children; anterolateral thigh is preferred site in neonates, infants and young children; not to be injected into the buttock (vaccine efficacy reduced).

MMR

MMR (measles, mumps and rubella) is a live vaccine. It should not be given to immunocompromised individuals (see section 8) (1). All pretransplant patients require a MMR vaccine as part of their childhood vaccines. The second MMR can be given at 16 months of age (interval of at least 3 months after the first vaccine) (2) if the child is in ESRF/CKD stage 5 and will be active on the transplant list before their pre-school vaccines.

Children <4years with eGFR <30ml/min/1.73m² should have their preschool booster brought forward. (2)

If a child is over 10 years old and missed their primary vaccine schedule then the two MMR vaccines can be given 1 month apart. (11)

All children with NS who have their childhood vaccination schedule interrupted due to high dose steroids or other immunosuppressants should have their second MMR as soon as possible. MMR vaccine can be given when high dose steroids have been discontinued for at least 3 months or on low dose steroids for at least 3 months (see Appendix II). Occasionally, individuals on lower doses of steroids may be immunosuppressed and at increased risk from infections. In those cases, live vaccines should be considered with caution, in discussion with their consultant. All other immunosuppressants have to be discontinued for at least 6 months before considering the MMR vaccine (see section 8). 

MMR is a live vaccine and the recommendations about timing when it can be given with other live vaccines has changed (7), see Appendix IV for guidance when giving at the same time as varicella vaccine and the montoux test. 

Check measles antibody response 2-4 weeks after completing MMR course. If seroconversion is not confirmed a third dose may need to be given (2).

Patients cannot be listed on the Transplant List for at least 1 month following MMR vaccine (2).

Pneumococcal Polysaccharide Vaccine  (PPV) (5)

PPV containing vaccines are inactivated (not live): they do not contain live organisms and cannot cause the diseases against which they protect.

Pneumococcal polysaccharide vaccine (Pneumovax II) contains purified capsular polysaccharide from each of 23 capsular types of pneumococcus. All children with chronic kidney disease over 2 years of age will need a single dose of PPV to provide protection against the serotypes of S. Pneumoniae not covered by the primary immunisation course with Pneumococcal conjugate vaccine  (PCV). All children should have completed Pneumococcal conjugate vaccine as part of their routine childhood immunisation programme. 

Children younger than two years of age show poor antibody responses to immunisation with PPV and therefore it is not suitable for this age group.

Dosage schedule by intramuscular*injection:

Age >2 years: A single dose of 0.5ml of PPV

*PPV are routinely given into the upper arm in children and adults or the anterolateral thigh in infants under one year of age unless they have a bleeding disorder then see Green Book.

Varicella Vaccine

Varicella vaccine is a live vaccine. It should not be given to immunocompromised individuals (see section 8) (12).

All pre-transplant patients who are varicella zoster virus (VZV) IgG negative on testing will be given the varicella vaccine. 

Ensure lymphocyte count >1.2-109/L

Delay for 5 months if patient has received immunoglobulins or blood transfusion.

Salicylates should be avoided for 6 weeks after vaccine.

All children with NS who are VZV IgG negative on testing will be given the varicella vaccine when high dose steroids have been discontinued for at least 3 months or on low dose steroids for at least 3 months (see Appendix II). Occasionally, individuals on lower doses of steroids may be immunosuppressed and at increased risk from infections. In those cases, live vaccines should be considered with caution, in discussion with their consultant. All other immunosuppressants have to be discontinued for at least 6 months before considering the varicella vaccine (see section 8). 

Varicella is a live vaccine and the recommendations about timing when it can be given with other live vaccines has changed (7), see Appendix IV for guidance when giving at the same time as MMR. 

Dosage schedule for Varilrix® by deep subcutaneous injection (12): 

Age > 1 year - two doses of 0.5ml, 4-8 weeks apart (not less than four weeks apart.)

Varicella vaccine should ideally be given at the same time as other live vaccines such as MMR. If live vaccines cannot be administered simultaneously, a four-week interval is recommended.

Patients cannot be listed on the Transplant List for at least 1 month following varicella vaccine if seroconversion demonstrated (2), however Infectious Disease Consultants in the RHC do not recommend testing for seroconversion as immunity is assumed when 2 doses given. ELISA is not always  sensitive enough to pick up vaccine induced immunity. 

Influenza Vaccine

From September 2013 a new live Intranasal Influenza Vaccine was introduced to the Childhood Vaccine Schedule for all 2-11 year olds (6). It should not be given to immunocompromised individuals (see section 8) and children active on the Transplant list. 

This vaccination is given yearly by the GP.

Inactivated Influenza Injection Vaccine 

Seasonal influenza injection vaccine is an inactivated (not live) vaccine and should be given yearly to all children over 6 months with chronic kidney failure, CKD  stages 3, 4 or 5, nephrotic syndrome and kidney transplantation.

Influenza Intranasal Vaccine

There is a LIVE intranasal influenza vaccine that should be avoided in all immunocompromised individuals (see section 8) and children active on the Transplant list. (13)  

Contraindications and special considerations (14)

Live vaccines can, in some situations, cause severe or fatal infections in immunosuppressed individuals due to extensive replication of the vaccine strain. For this reason, severely immunosuppressed individuals [for a comprehensive and up to date list see chapter 6 of the Green Book (14)] should not be given live vaccines, and vaccination in immunosuppressed individuals should only be conducted in consultation with an appropriate specialist.

Inactivated vaccines cannot replicate and so may be administered to immunosuppressed individuals, although they may elicit a lower response than in immunocompetent individuals.

High Dose Steroids

Live vaccines should be avoided in patients receiving systemic high-dose steroids, until at least three months after treatment has stopped. This would include:

  • adults and children on high-dose corticosteroids (>40mg prednisolone per day or 2mg/kg/day in children under 20kg) for more than 1 week
  • adults and children on lower dose corticosteroids (>20mg prednisolone per day or1mg/kg/day in children under 20kg) for more than 14 days
  • Occasionally, individuals on lower doses of steroids may be immunosuppressed and at increased risk from infections. In those cases, live vaccines should be considered with caution, in discussion with their consultant.

Other Immunosuppressive Drugs including Biologics

Please read comprehensive list in chapter 6 in the Green Book (14).

https://assets.publishing.service.gov.uk/government/uploads/system/uplo ads/attachment_data/file/655225/Greenbook_chapter_6.pdf

Appendix I: Renal Transplant Vaccine Record

Renal Transplant Vaccine Record - Save with patients transplant work-up plan:

Vaccine

Date

Comments

DTaP/IPV/Hib/HepB (Infanrix hexa®)

2 months 1st :
3 months 2nd:
4 months 3rd :

 All children born after 1/8/17 

MenB (Bexsero®)

2 months 1st :
4 months 2nd:
12-13 months 3rd :

 

PCV  (Prevenar)

2 months 1st :
4 months 2nd:
12-13 months 3rd :

 

Rotavirus (Live) (oral)

2 months 1st :
3 months 2nd:

If 1st dose not given by 15weeks of age then it is not given at all

Hib/MenC (Menitorix)

12-13 months

 

MMR (Live) (Priorix or MMR VaxPRO)

12-13 months 1st :
3yrs 4 months 2nd:

 

Influenza (Live) (nasal spray)

2-11 years 1st:
2-9 years 2nd:

Injection to be given if Live vaccine CI

dTaP/IPV(Repevax) or
DTaP/IPV(Infanrix-IPV)

3yrs 4 months

 

HPV (females only) (Gardasil)

11-13 years

 

MenACWY
(Nimenrix)

14 years

 

Td/IPV (Revaxis)

14 years

Check MMR status unless already transplanted

Hep B

1st:
2nd:
3rd:
4th:

Check Hep B status for all children born after 1/8/17 

Varicella (Live)

1st :
2nd:

 

BCG (Live)

 

 

Influenza Injection(>6months old)

Annually at GP

See note above 

Pneumococcal (PPV)

At risk children >2years old

Every 5 years

Appendix II: Safety of vaccines in children with Nephrotic Syndrome or on immunosuppressants

Vaccine

Immunosuppressant†

High dose steroids*

Low dose steroids**

DTaP/IPV/Hib

Yes

Yes

Yes

Men: C,B & ACWY

Yes

Yes

Yes

dTaP/IPV or DTaP/IPV

Yes

Yes

Yes

Td/IPV

Yes

Yes

Yes

Hep B

Yes

Yes

Yes

PCV/PPV

Yes

Yes

Yes

HPV

Yes

Yes

Yes

Influenza (injection)

Yes

Yes

Yes

 

 

 

 

Varicella(live)

No

No

Yes

BCG(live)

No

No

Yes

MMR(live)

No

No

Yes

Influenza(live)  (nasal spray)

No

No

Yes

Rotavirus(live)

No

No

Yes

See Chapter 6 in the Green Book (14) for full comprehensive list.

* High dose steroids

  • adults and children on high-dose corticosteroids (>40mg prednisolone per day or 2mg/kg/day in children under 20kg) for more than 1 week
  • adults and children on lower dose corticosteroids (>20mg prednisolone per day or 1mg/kg/day in children under 20kg) for more than 14 days

** Low dose steroids

  • Live vaccines cannot be given until 3 months after stopping high dose steroids and changing to low dose steroids
  • Low dose steroid will depend on the weight of the child and dose of steroid, this will be a clinical decision
  • Occasionally, individuals on lower doses of steroids may be immunosuppressed and at increased risk from infections. In those cases, live vaccines should be considered with caution, in discussion with a relevant specialist physician

†Immunosuppressive drugs

Patients receiving other types of immunosuppressive drugs (e.g. azathioprine, ciclosporin, tacrolimus, cyclophosphamide, rituximab and the newer cytokine inhibitors) alone or in combination with lower doses of steroids, until at least six months after terminating such treatment. The advice of the physician in charge or immunologist should be sought.

°BCG Vaccine

This vaccine is not routinely given to children with NS.  It is in this table for information only.

Appendix III: Nephrotic Syndrome Vaccine Record

Vaccine

Date

Comments

DTaP/IPV/Hib/HepB (Infanrix hexa®)

2 months 1st :
3 months 2nd:
4 months 3rd :

 All children born after 1/8/17 

MenB (Bexsero®)

2 months 1st :
4 months 2nd:
12-13 months 3rd :

 

PCV  (Prevenar)

2 months 1st :
4 months 2nd:
12-13 months 3rd :

 

Rotavirus (Live) (oral)

2 months 1st :
3 months 2nd:

If 1st dose not given by 15weeks of age then it is not given at all

Hib/MenC
(Menitorix)

12-13 months

 

MMR (Live) (Priorix or MMR VaxPRO)

12-13 months 1st :
3yrs 4 months 2nd:

 

Influenza (Live) (nasal spray)

2-11 years 1st:
2-9 years 2nd:

Injection to be given if Live vaccine CI

dTaP/IPV(Repevax) or
DTaP/IPV(Infanrix-IPV)

3yrs 4 months

 

HPV (females only) (Gardasil)

11-13 years

 

MenACWY
(Nimenrix)

14 years

 

Td/IPV (Revaxis)

14 years

Check MMR status unless immunosuppressed

 

 

 

Varicella (Live)

 

1st :
2nd:

 

 

 

 

Influenza Injection(>6months old)

Annually at GP

See note above 

Pneumococcal (PPV)

At risk - see 6.4.3

Every 5 years

 

Appendix IV: Administration of More Than One Live Vaccine

 Yellow Fever and MMR

 A four week minimum interval period should be observed between the administration of these two vaccines. Yellow Fever and MMR should not be administered on the same day.

 Varicella (and zoster) vaccine and MMR

 If these vaccines are not administered on the same day, then a four week minimum interval should be observed between vaccines.

 Tuberculin skin testing (Mantoux) and MMR

 If a tuberculin skin test has already been initiated, then MMR should be delayed until the skin test has been read unless protection against measles is required urgently. If a child has had a recent MMR, and requires a tuberculin test, then a four week interval should be observed.

All currently used live vaccines (BCG, rotavirus, live attenuated influenza vaccine (LAIV), oral typhoid vaccine, yellow fever, varicella, zoster and MMR) and tuberculin (Mantoux) skin testing.

 Apart from those combinations listed above, these live vaccines can be administered at any time before or after each other. This includes tuberculin (mantoux) skin testing.

Appendix V: Abbreviations

 

dTaP/IPV – Adsorbed Diphtheria (low dose) Tetanus Pertussis / Poliomyelitis (inactivated)

DTaP/IPV – Diphtheria Tetanus Pertussis / Poliomyelitis  (inactivated)                     

DTaP/IPV/Hib/HepB – Diphtheria Tetanus Pertussis / Poliomyelitis (inactivated) / Haemophilus influenzae (type b)/ Hepatitis B

Hib – Haemophilus influenzae (type b)

HPV – Human papillomavirus

IPV – Poliomyelitis (inactivated)

MenB - Meningococcal type B

MenC – Meningococcal type C

MenACWY – Meningococcal types ACWY

MMR – Measles Mumps Rubella

Td/IPV – Tetanus Adsorbed Diphtheria (low dose) / Poliomyelitis (inactivated)

PCV – Pneumococcal Conjugate Vaccine

PPV – Pneumococcal Polysaccharide Vaccine

References
  1. Green Book ‘Immunisation Against Infectious Disease’ 
  2. Rees L., Webb N., Brockehauer D, Brogan P., Paediatric Nephrology. 2nd ed. Oxford: Oxford University Press; 2012
  3. immunisationscotland.org.uk
  4. Vaccination of Individuals with Uncertain or Incomplete Immunisation Status Green Book Chapter 11
  5. Pneumococcal Update January 2018 Chapter 25 On line Green Book 
  6. Influenza Updated December 2017 Chapter 19 On line Green Book 
  7. Public Health England 2015 Revised recommendations for the administration of more than one live vaccine
  8. Tuberculosis Update April 2013 Chapter 32 On line Green Book 
  9. Hepatitis B Updated July 2017 Chapter 18 On line Green Book 
  10. The Renal Association Guideline Blood Borne Virus Infection (5.1-5.8) 
  11. Rubella Update April 2013 Chapter 28 On line Green Book
  12. Varicella Update August 2015 Chapter 34 On line Green Book 
  13. Verbal Communication from Renal Unit RHC Glasgow 2016
  14. Contraindications and special considerations August 2017 Chapter 6 Green Book
Editorial Information

Last reviewed: 21 August 2018

Next review: 01 September 2020

Author(s): Angela Lamb

Co-Author(s): Membership of the Guideline Development Group: Mrs Angela Lamb, Paediatric Renal Pharmacist; Dr David Hughes, Consultant Paediatric Nephrologist; Dr Victoria Harkins, ST6; Sr Diane King, Renal Nurse Specialist; Ursula Monachan, Renal Advanced Nurse Practitioner

Approved By: Paediatric Drugs & Therapeutics Committee