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Evaluation of timing of first vaccination in children after hematopoietic allogeneic stem cell transplantation
European Journal of Oncology Nursing 21 (2016) 212e214
Contents lists available at ScienceDirect
European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
Practice note
Evaluation of timing of first vaccination in children after hematopoietic allogeneic stem cell transplantation Tiene Bauters a, *, Victoria Bordon Cueto De Braem a, Petra Schelstraete b, ve Laureys a, Yves Benoit a, Catharina Dhooge a Sophie Van Lancker a, Genevie a
Department of Pediatric Hemato-Oncology and Hematopoietic Stem Cell Transplantation, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium Department of Pediatric Pulmonology and Infectious Diseases, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 December 2014 Received in revised form 3 September 2015 Accepted 26 October 2015
Purpose: Protective immunity to vaccine preventable infectious diseases might be lost over time following hematopoietic stem cell transplantation (HSCT). Limited data are available on the appropriate follow-up of vaccination schedules in pediatric HSCT patients. This study aims to ascertain whether the guidelines for vaccination recommended in our hospital are followed and to which extent of conformity they are used. Methods: A 5-year survey, including all pediatric allogeneic HSCT patients, transplanted at the Ghent University hospital, Belgium. Data were collected from the patient's electronic (nursing and medical) charts. Results: Data on vaccination schedules of 28 patients (54.9%) eligible for the recommended vaccinations were collected. Eleven patients (11/28; 39.3%) were vaccinated timely. In 14 out of 17 patients (82.4%) vaccination was postponed for medical reasons, while vaccination was postponed without medical reason in 17.6% (3/17). Vaccination data could not be retrieved in 43.1 (22/51) of patients. Vaccination was declined by the parents in one patient (2.0%). Conclusion: There is high level of agreement between the hospital guideline and the vaccination of pediatric HSCT patients. Health-care providers play a crucial role in effectively appropriate follow-up of vaccination schedules. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Pediatrics Vaccination Hematopoietic stem cell transplantation Compliance
1. Introduction The number of hematopoietic stem cell transplantations (HSCT) in children has increased steadily over the last decades. Specific protective immunity to vaccine preventable infectious diseases as achieved after childhood immunization might be lost following HSCT (Patel et al., 2008). In addition, decreased immunity after HSCT puts patients at risk of diminished responses to vaccines and/ or even serious adverse events following certain (e.g. live) vaccines. The degree of immunity depends on the myeloablative regimen used, delay in immune reconstitution, presence of graft versus host disease, degree of post-transplant immune suppression and the immune status of the donor. Different professional organizations have established vaccination
* Corresponding author. E-mail address: [email protected] (T. Bauters). http://dx.doi.org/10.1016/j.ejon.2015.10.006 1462-3889/© 2015 Elsevier Ltd. All rights reserved.
guidelines for this immunocompromised population (Centers for Disease Control and Prevention, Infectious Diseases Society of America, European Bone Marrow Transplantation, …). The Pediatric Working Group on Bone Marrow and Blood Stem Cell Transplantation recommends early and complete revaccination of children starting at 6 months after transplantation (Meisel et al., 2007). Systematic reimmunization after HSCT is important to re-establish appropriate immunity and to prevent infectious diseases related morbidity and mortality. Data are available on the appropriate follow-up of and adherence on vaccination schedules in adults (Lerchenfeldt et al., 2013), but as far as we know, no data are published in the pediatric population so far. In this study, we aimed to ascertain whether the guidelines for revaccination after HSCT, as recommended in our hospital are followed. In addition, the reasons for missed or delayed vaccinations were analyzed in order to optimize adherence strategies and follow-up. As the entire revaccination process requires some
T. Bauters et al. / European Journal of Oncology Nursing 21 (2016) 212e214
months, the date of the first revaccination was set as a reference point.
Table 2 Patient characteristics. Number of transplantations Number of patients Sex Male Female Median age at HSCT (years) Conditioning regimen TBI No TBI Diagnosis Leukemia (acute and chronic) Primary immune deficiency Myelodysplastic syndrome Inborn errors of metabolism Severe aplastic anemia Hemoglobinopathy
2. Patients and methods 2.1. Patients and setting This was a retrospective, single-center study reviewing vaccination data of all pediatric HSCT patients of the Ghent University hospital, Belgium, during a 5-year period (2007e2012). All pediatric patients (0e18 year) who were post allogeneic transplant (at least 6 months before the start of the study) were included. As according to the hospital's immunization schedule, the first planned vaccination after HSCT is the pneumococcal vaccination (i.e., at 6 months after the date of transplantation), this date of vaccination was used as a reference point (Table 1). Vaccinations on-schedule were those administered in the timeframe between HSCT and vaccination as recommended in the hospital guideline, i.e. 6 months post-transplantation (with a deviation of ± 4 weeks). For postponed vaccinations (i.e., more than the defined deviation of 4 weeks), a distinction was made between postponed vaccination with or without a medical reason. Patients' electronic medical and nursing charts were reviewed for the timing of administration of the pneumococcal vaccination, as this is the first vaccination (reference point) to be given according to the vaccination schedule. We undertook this study to ascertain whether the guidelines as established in our hospital were followed and to which extent. 2.2. Ethical considerations Approval of the institutional ethics committee was obtained.
213
51 48 30 18 7 11 40 22 16 5 5 2 1
insufficient immune reconstitution (e.g. insufficient amount of Bcells) (8/14; 57.1%), on-going immune suppressive therapy for graftversus-host-disease (5/14; 35.7%) and auto-immune phenomenon post-allogeneic transplantation (1/14; 7.2%). Vaccination was postponed without medical reason 17.6% (3/ 17), i.e. in a minority of the patients., of which one patient due to non-compliance. In the remaining two start of vaccination was delayed with 3 and 4 weeks, respectively. Vaccination data could not be retrieved in 43.1% (22/51) of patients. The reason was death of the patients before start of vaccination in 72.7% (16/22), disease relapse in 18.2% (4/22) and followup in another hospital in 9.1% (2/22) For 1 patient (2.0%), vaccination was declined by the parents. An overview of the vaccination status of transplanted patients is listed in Table 3.
3. Results
4. Discussion
3.1. Demographic and transplant characteristics
Timely vaccination of children after HSCT is important. As these children are at high risk of exposure to infectious diseases (e.g. in day care centers or at school) and children have a faster immune reconstitution immunizations should not be delayed. Therefore, a timely start and close follow-up of the vaccination schedules is of utmost importance. The time of the first vaccination was used a reference point in our study. Our study demonstrates highly positive results as demonstrated by the number of vaccinated patients, and patients with postponed vaccination for medical reason. In only a small number of patients (3/17) eligible for vaccination, vaccination was postponed without medical reason, more especially a delay of start of vaccination (2 patients) and non-compliance (1 patient). This is in contrast to reports in the adults, demonstrating/ showing that missed and delayed vaccinations are common in this population (Lerchenfeldt et al., 2013). One explanation for the good agreement might be the regular and close follow-up by parents and
The data of 48 patients (30 males; median age at time of HSCT: 7 years; range 5 monthse17.7 year) included in the dataset are presented in Table 2. As 3 patients underwent two transplantations, the total number of transplants were 51. Conditioning regimens included myeloablative regimens (n ¼ 42), reduced intensity conditioning regimens (n ¼ 4) and patients transplanted without conditioning regimen (n ¼ 5). Eleven patients underwent total body irradiation (TBI). 3.2. Vaccination schedules Data on vaccination schedules of 28 patients (54.9%) eligible for the recommended vaccinations were collected. Eleven patients (11/ 28; 39.3%) were vaccinated timely. In 14 out of 17 patients (82.4%) vaccination was postponed for medical reasons. They included
Table 1 Guideline for post-allogeneic transplant vaccination schedule, as established in the pediatric HSCT unit of the Ghent University Hospital. Vaccine
Post-transplant 6 months
Measles, Mumps, Rubella Meningococci C Pneumococci Haemophilus Influenzae B Hepatitis B Inactivated poliomyelitis, Diphteria, tetanus, (Bordetellaa) a
vaccination after HSCT (patients younger than 7 years).
12 months
14 months
16 months
24 months
X X X X X
X X X
X X X
214
T. Bauters et al. / European Journal of Oncology Nursing 21 (2016) 212e214
Table 3 Vaccination status of transplanted patients.
Number of transplantations Vaccinated patients On-schedule Postponed vaccination Postponed vaccination (medical reason) Insufficient immune reconstitution On-going immune suppressive therapy (GvHD) Auto-immune phenomenon post-allo transplantation Postponed vaccination (without medical reason) No medical reason Non-adherence No vaccination data available Dead before start vaccination Disease Relapse Follow up in other hospital Not vaccinated Declined by parents
N
%
51 28/51 11/28 17/28 14/17 8/14 5/14 1/14 3/17 2/3 1/3 22/51 16/22 4/22 2/22
100 54.9 39.3 60.7 82.4 57.1 35.7 7.2 17.6 66.7 33.3 43.1 72.7 18.2 9.1
1/51
2.0
by their treating physicians in the post-transplant clinic. It is wellknown in pediatric hematology and oncology that parents are very involved in follow-up care once their child is discharged from the hospital (Dockerty et al., 2000). In addition, pediatricians are very familiar with vaccination and are alert to this issue. In order to optimize the follow-up of vaccination after HSCT, we are implementing an electronic alert system during consultations at the post-transplant clinic. In Flanders, a web-based vaccination database exists, (www. vaccinnet.be), providing information on vaccination status. However, this database doesn't enable vaccine alerts (e.g. no administration of live vaccines in certain patient populations). Another tool that helps allogeneic and autologous transplant recipients understand and prepare their post-transplant follow-up care is a free app that provides the recommended tests and evaluations for six-month, 12-month and annual appointments
(https://bethematchclinical.org/Post-Transplant-Care/ Vaccinations/). It must be mentioned that our vaccination schedule was meanwhile adapted according to the most recent guidelines. 5. Conclusion There is a high level of agreement between the hospital guideline and the timing of revaccination start of pediatric HSCT patients eligible for vaccination, demonstrating that our pediatric posttransplant patients are followed closely and adequately. Health-care providers play a crucial role in appropriate followup of vaccination schedules and provision of information on benefits and possible risk of vaccination to parents of immunocompromised patients. Conflicts of interest None declared. References Dockerty, J., Williams, S., McGee, R., Skegg, D., 2000. Impact of childhood cancer on the mental health of parents. Med. Pediatr. Oncol. 35 (5), 475e483. Lerchenfeldt, S.M., Cronin, S.M., Chandrasekar, P.H., 2013. Vaccination adherence in hematopoietic stem cell transplant patients: a pilot study on the impact of vaccination cards and reminder telephone calls. Transpl. Infect. Dis. 15 (6), 634e638. Meisel, R., Kuypers, L., Dirksen, U., et al., Impfung von Kindern nach allogener Stammzelltransplantation (IKAST) Study Group, 2007. Pneumococcal conjugate vaccine provides early protective antibody responses in children after related and unrelated allogeneic hematopoietic stem cell transplantation. Blood 109 (6), 2322e2326. Patel, S.R., Chisholm, J.C., Heath, P.T., 2008. Vaccinations in children treated with standard-dose cancer therapy or hematopoietic stem cell transplantation. Pediatr. Clin. N. Am. 55 (1), 169e186. Post transplant care guide. https://bethematchclinical.org/Post-Transplant-Care/ Vaccinations/. (accessed 22.12.14.).
Contents lists available at ScienceDirect
European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
Practice note
Evaluation of timing of first vaccination in children after hematopoietic allogeneic stem cell transplantation Tiene Bauters a, *, Victoria Bordon Cueto De Braem a, Petra Schelstraete b, ve Laureys a, Yves Benoit a, Catharina Dhooge a Sophie Van Lancker a, Genevie a
Department of Pediatric Hemato-Oncology and Hematopoietic Stem Cell Transplantation, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium Department of Pediatric Pulmonology and Infectious Diseases, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 December 2014 Received in revised form 3 September 2015 Accepted 26 October 2015
Purpose: Protective immunity to vaccine preventable infectious diseases might be lost over time following hematopoietic stem cell transplantation (HSCT). Limited data are available on the appropriate follow-up of vaccination schedules in pediatric HSCT patients. This study aims to ascertain whether the guidelines for vaccination recommended in our hospital are followed and to which extent of conformity they are used. Methods: A 5-year survey, including all pediatric allogeneic HSCT patients, transplanted at the Ghent University hospital, Belgium. Data were collected from the patient's electronic (nursing and medical) charts. Results: Data on vaccination schedules of 28 patients (54.9%) eligible for the recommended vaccinations were collected. Eleven patients (11/28; 39.3%) were vaccinated timely. In 14 out of 17 patients (82.4%) vaccination was postponed for medical reasons, while vaccination was postponed without medical reason in 17.6% (3/17). Vaccination data could not be retrieved in 43.1 (22/51) of patients. Vaccination was declined by the parents in one patient (2.0%). Conclusion: There is high level of agreement between the hospital guideline and the vaccination of pediatric HSCT patients. Health-care providers play a crucial role in effectively appropriate follow-up of vaccination schedules. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Pediatrics Vaccination Hematopoietic stem cell transplantation Compliance
1. Introduction The number of hematopoietic stem cell transplantations (HSCT) in children has increased steadily over the last decades. Specific protective immunity to vaccine preventable infectious diseases as achieved after childhood immunization might be lost following HSCT (Patel et al., 2008). In addition, decreased immunity after HSCT puts patients at risk of diminished responses to vaccines and/ or even serious adverse events following certain (e.g. live) vaccines. The degree of immunity depends on the myeloablative regimen used, delay in immune reconstitution, presence of graft versus host disease, degree of post-transplant immune suppression and the immune status of the donor. Different professional organizations have established vaccination
* Corresponding author. E-mail address: [email protected] (T. Bauters). http://dx.doi.org/10.1016/j.ejon.2015.10.006 1462-3889/© 2015 Elsevier Ltd. All rights reserved.
guidelines for this immunocompromised population (Centers for Disease Control and Prevention, Infectious Diseases Society of America, European Bone Marrow Transplantation, …). The Pediatric Working Group on Bone Marrow and Blood Stem Cell Transplantation recommends early and complete revaccination of children starting at 6 months after transplantation (Meisel et al., 2007). Systematic reimmunization after HSCT is important to re-establish appropriate immunity and to prevent infectious diseases related morbidity and mortality. Data are available on the appropriate follow-up of and adherence on vaccination schedules in adults (Lerchenfeldt et al., 2013), but as far as we know, no data are published in the pediatric population so far. In this study, we aimed to ascertain whether the guidelines for revaccination after HSCT, as recommended in our hospital are followed. In addition, the reasons for missed or delayed vaccinations were analyzed in order to optimize adherence strategies and follow-up. As the entire revaccination process requires some
T. Bauters et al. / European Journal of Oncology Nursing 21 (2016) 212e214
months, the date of the first revaccination was set as a reference point.
Table 2 Patient characteristics. Number of transplantations Number of patients Sex Male Female Median age at HSCT (years) Conditioning regimen TBI No TBI Diagnosis Leukemia (acute and chronic) Primary immune deficiency Myelodysplastic syndrome Inborn errors of metabolism Severe aplastic anemia Hemoglobinopathy
2. Patients and methods 2.1. Patients and setting This was a retrospective, single-center study reviewing vaccination data of all pediatric HSCT patients of the Ghent University hospital, Belgium, during a 5-year period (2007e2012). All pediatric patients (0e18 year) who were post allogeneic transplant (at least 6 months before the start of the study) were included. As according to the hospital's immunization schedule, the first planned vaccination after HSCT is the pneumococcal vaccination (i.e., at 6 months after the date of transplantation), this date of vaccination was used as a reference point (Table 1). Vaccinations on-schedule were those administered in the timeframe between HSCT and vaccination as recommended in the hospital guideline, i.e. 6 months post-transplantation (with a deviation of ± 4 weeks). For postponed vaccinations (i.e., more than the defined deviation of 4 weeks), a distinction was made between postponed vaccination with or without a medical reason. Patients' electronic medical and nursing charts were reviewed for the timing of administration of the pneumococcal vaccination, as this is the first vaccination (reference point) to be given according to the vaccination schedule. We undertook this study to ascertain whether the guidelines as established in our hospital were followed and to which extent. 2.2. Ethical considerations Approval of the institutional ethics committee was obtained.
213
51 48 30 18 7 11 40 22 16 5 5 2 1
insufficient immune reconstitution (e.g. insufficient amount of Bcells) (8/14; 57.1%), on-going immune suppressive therapy for graftversus-host-disease (5/14; 35.7%) and auto-immune phenomenon post-allogeneic transplantation (1/14; 7.2%). Vaccination was postponed without medical reason 17.6% (3/ 17), i.e. in a minority of the patients., of which one patient due to non-compliance. In the remaining two start of vaccination was delayed with 3 and 4 weeks, respectively. Vaccination data could not be retrieved in 43.1% (22/51) of patients. The reason was death of the patients before start of vaccination in 72.7% (16/22), disease relapse in 18.2% (4/22) and followup in another hospital in 9.1% (2/22) For 1 patient (2.0%), vaccination was declined by the parents. An overview of the vaccination status of transplanted patients is listed in Table 3.
3. Results
4. Discussion
3.1. Demographic and transplant characteristics
Timely vaccination of children after HSCT is important. As these children are at high risk of exposure to infectious diseases (e.g. in day care centers or at school) and children have a faster immune reconstitution immunizations should not be delayed. Therefore, a timely start and close follow-up of the vaccination schedules is of utmost importance. The time of the first vaccination was used a reference point in our study. Our study demonstrates highly positive results as demonstrated by the number of vaccinated patients, and patients with postponed vaccination for medical reason. In only a small number of patients (3/17) eligible for vaccination, vaccination was postponed without medical reason, more especially a delay of start of vaccination (2 patients) and non-compliance (1 patient). This is in contrast to reports in the adults, demonstrating/ showing that missed and delayed vaccinations are common in this population (Lerchenfeldt et al., 2013). One explanation for the good agreement might be the regular and close follow-up by parents and
The data of 48 patients (30 males; median age at time of HSCT: 7 years; range 5 monthse17.7 year) included in the dataset are presented in Table 2. As 3 patients underwent two transplantations, the total number of transplants were 51. Conditioning regimens included myeloablative regimens (n ¼ 42), reduced intensity conditioning regimens (n ¼ 4) and patients transplanted without conditioning regimen (n ¼ 5). Eleven patients underwent total body irradiation (TBI). 3.2. Vaccination schedules Data on vaccination schedules of 28 patients (54.9%) eligible for the recommended vaccinations were collected. Eleven patients (11/ 28; 39.3%) were vaccinated timely. In 14 out of 17 patients (82.4%) vaccination was postponed for medical reasons. They included
Table 1 Guideline for post-allogeneic transplant vaccination schedule, as established in the pediatric HSCT unit of the Ghent University Hospital. Vaccine
Post-transplant 6 months
Measles, Mumps, Rubella Meningococci C Pneumococci Haemophilus Influenzae B Hepatitis B Inactivated poliomyelitis, Diphteria, tetanus, (Bordetellaa) a
vaccination after HSCT (patients younger than 7 years).
12 months
14 months
16 months
24 months
X X X X X
X X X
X X X
214
T. Bauters et al. / European Journal of Oncology Nursing 21 (2016) 212e214
Table 3 Vaccination status of transplanted patients.
Number of transplantations Vaccinated patients On-schedule Postponed vaccination Postponed vaccination (medical reason) Insufficient immune reconstitution On-going immune suppressive therapy (GvHD) Auto-immune phenomenon post-allo transplantation Postponed vaccination (without medical reason) No medical reason Non-adherence No vaccination data available Dead before start vaccination Disease Relapse Follow up in other hospital Not vaccinated Declined by parents
N
%
51 28/51 11/28 17/28 14/17 8/14 5/14 1/14 3/17 2/3 1/3 22/51 16/22 4/22 2/22
100 54.9 39.3 60.7 82.4 57.1 35.7 7.2 17.6 66.7 33.3 43.1 72.7 18.2 9.1
1/51
2.0
by their treating physicians in the post-transplant clinic. It is wellknown in pediatric hematology and oncology that parents are very involved in follow-up care once their child is discharged from the hospital (Dockerty et al., 2000). In addition, pediatricians are very familiar with vaccination and are alert to this issue. In order to optimize the follow-up of vaccination after HSCT, we are implementing an electronic alert system during consultations at the post-transplant clinic. In Flanders, a web-based vaccination database exists, (www. vaccinnet.be), providing information on vaccination status. However, this database doesn't enable vaccine alerts (e.g. no administration of live vaccines in certain patient populations). Another tool that helps allogeneic and autologous transplant recipients understand and prepare their post-transplant follow-up care is a free app that provides the recommended tests and evaluations for six-month, 12-month and annual appointments
(https://bethematchclinical.org/Post-Transplant-Care/ Vaccinations/). It must be mentioned that our vaccination schedule was meanwhile adapted according to the most recent guidelines. 5. Conclusion There is a high level of agreement between the hospital guideline and the timing of revaccination start of pediatric HSCT patients eligible for vaccination, demonstrating that our pediatric posttransplant patients are followed closely and adequately. Health-care providers play a crucial role in appropriate followup of vaccination schedules and provision of information on benefits and possible risk of vaccination to parents of immunocompromised patients. Conflicts of interest None declared. References Dockerty, J., Williams, S., McGee, R., Skegg, D., 2000. Impact of childhood cancer on the mental health of parents. Med. Pediatr. Oncol. 35 (5), 475e483. Lerchenfeldt, S.M., Cronin, S.M., Chandrasekar, P.H., 2013. Vaccination adherence in hematopoietic stem cell transplant patients: a pilot study on the impact of vaccination cards and reminder telephone calls. Transpl. Infect. Dis. 15 (6), 634e638. Meisel, R., Kuypers, L., Dirksen, U., et al., Impfung von Kindern nach allogener Stammzelltransplantation (IKAST) Study Group, 2007. Pneumococcal conjugate vaccine provides early protective antibody responses in children after related and unrelated allogeneic hematopoietic stem cell transplantation. Blood 109 (6), 2322e2326. Patel, S.R., Chisholm, J.C., Heath, P.T., 2008. Vaccinations in children treated with standard-dose cancer therapy or hematopoietic stem cell transplantation. Pediatr. Clin. N. Am. 55 (1), 169e186. Post transplant care guide. https://bethematchclinical.org/Post-Transplant-Care/ Vaccinations/. (accessed 22.12.14.).