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Kids and Germs, Forever the Twain Shall Meet, Even After Transplant

Michele Estabrook, MD
St. Louis Children's Hospital

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michele estabrookKids who have had a lung or heart transplant are given a second chance to do what they really want which is to be like any other kid. They want to go back to school, hang out with friends, go swimming, join the baseball team, go on play dates (or dates) and have birthday parties.

Families return to their normal routines which often means daycare or after school care. Kids happily go out into the world of viruses, bacteria and yes—even head lice—but they are like Petri dishes: they catch it all and then bring it home to share with the rest of the family.

Children normally can have up to ten, self-resolving viral illnesses per year in the first 2-3 years of life; however, when that child is post-transplant, the anxiety can be great.

The best way to protect children from infection was invented at the end of the 18th century with the discovery and development of disease-preventing inoculations (read more in the 2012 February Issue, Vol. 3, Issue 9, Light, Beer, Shots, and Mad Dogs and Phlegming: Perchance a Mould, Diligence, and Chivalry). We now have at least 15 different bacterial and viral illnesses which can be prevented or ameliorated by vaccines routinely given to all children.

The pediatric inoculation schedule begins at birth and stretches into adolescence. Given the fact that all vaccines work better before transplantation, and live viral vaccines against measles, mumps, rubella, chicken pox, and rotavirus are not recommended after transplantation, educating parents and health care providers on the recommended immunization guidelines for all children, regardless of chronic illness, will ensure that they arrive at their transplant window as fully protected as possible. The CDC's Advisory Committee on Immunization Practices (ACIP) provides yearly, updated, online schedules and guidelines as well as "catch-up" schedules for kids who are behind.

When the parent or care giver is asked, "are the immunizations up to date?" the answer is always, "yes." When the actual record is obtained and reviewed, however, there are usually opportunities for more immunizations. This review is an important component of the pre-transplant evaluation, keeping in mind that live viral vaccines should not be given less than 1-2 months pre-transplant. The CDC also gives detailed recommendations for the new 13-valent pneumococcal conjugate vaccine based on age and prior immunization status.

Finally, remember that immunizations don't stop in Kindergarten. Recommended adolescent vaccines are Tdap, meningococcal conjugate vaccine, HPV vaccine, and pneumococcal polysaccharide 23 vaccine when indicated. Children whose immunizations have been interrupted by transplant should resume the normal schedule with the exception of live viral vaccines. Data are lacking, but most centers resume immunizations 3-6 months post-transplant.

It is also important to create a protective environment around children after transplant by fully immunizing family and health care workers. With the exception of small pox and oral-polio vaccines, there is little risk of transmission from live vaccines and family members should receive recommended MMR and Varicella vaccines. The ACIP also believes that infants in the household of an immunocompromised individual should receive the rotavirus vaccine. Preventing transmission of wild-type virus to the post-transplant child outweighs any theoretical risk of vaccine strain disease.

There are a multitude of infections-mostly viral-that are not preventable by immunization and can cause more significant disease in the immunocompromised. Many are identified by antigen detection, PCR, or culture. Human metapneumovirus (hMPV) is increasingly recognized as a cause of respiratory tract infection in all age groups and disease can be severe in SOT recipients. Serological studies indicate that infection is nearly universal by 5 years of age and recurrent infections throughout life are common. Clinical manifestations including URI, bronchiolitis and pneumonia are similar to respiratory syncytial virus. RSV continues to peak every winter and is not yet preventable by immunization. Parainfluenza and adenovirus respiratory infection can occur year round. The average child under five years of age has 1-5 episodes of acute, viral gastroenteritis per year. Human calicivirus (Norovirus and Sapovirus), enteric adenovirus, and astrovirus are most common. Fortunately while still present, the incidence of rotavirus infection has been markedly decreased by the advent of infant vaccines.

What can be done to prevent community acquired infection? Careful attention to immunizations and good hand hygiene will go a long way. Otherwise, kids will be kids and they are bound to catch what is going around as they reenter their childhood.

Disclosure Statement: the author has no conflicts of interest to disclose.