Immunisation guideline for children with chronic kidney disease

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:

Vaccination of individuals with uncertain or incomplete immunisation status - GOV.UK (www.gov.uk)

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 1^st 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 1^st August 2017) (3)
• Pneumoccocal (every 5 years) (5)
• Inactivated Influenza Injection (yearly) (6)

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)

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)

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: 

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

An Anti-HBs antibody titre above 100iu/L (or above 10mIU/ml) 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 (or below 100mIU/ml) 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 mantoux 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)  

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).

Contraindications and special considerations: the green book, chapter 6 - GOV.UK (www.gov.uk)

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

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.

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