Contents

4 Immunisation of special groups

4.2 Infants with special immunisation considerations

4.2.1 Preterm and low birthweight infants

Vaccination as per the Schedule (ie, at the usual chronological age, with the usual vaccine dosage and interval) is recommended for preterm infants and infants with low birthweight. If an infant is in hospital when vaccination is due, the scheduled 6-week vaccines, with the exception of rotavirus vaccine (see below), should be given at the appropriate chronological age.

Rotavirus vaccine

Rotavirus vaccine is an exception to the above recommendation. It is best to vaccinate preterm infants as they leave hospital because of vaccine virus shedding in the stool. However, if discharge is not anticipated before age 15 weeks, which is the upper age limit for giving dose one, then giving rotavirus vaccine in hospital is acceptable. If standard universal precautions are maintained, administration of rotavirus vaccine to hospitalised infants, including hospitalised preterm infants, would be expected to carry a very low risk for transmission of vaccine viruses.5 Subsequent doses must be at least four weeks apart, with the third dose given before age 8 months and 0 days.

Hepatitis B vaccine

All preterm and low birthweight infants born to HBsAg-positive mothers should be managed the same way as term infants and receive immunoprophylaxis (HBIG and hepatitis B vaccine) as soon as possible after birth (see section 8.5.3). They should continue routine immunisation as per the Schedule, starting at age 6 weeks.

Influenza vaccine

Preterm infants who develop chronic lung disease are recommended to receive influenza vaccine once they are aged 6 months or older, and a second dose four weeks later (influenza vaccine is usually available from March to July each year). Influenza vaccine is recommended (but not funded) for close contacts of preterm infants, including children (see section 10.5).

Pertussis vaccine (for contacts)

It is essential that siblings of preterm infants be up to date with immunisations to reduce the risk of pertussis transmission to vulnerable infants (see section 14.5). Adolescents should have received Tdap in year 7 as part of the Schedule. Pertussis-containing vaccine is funded for primary and catch-up immunisation of all children aged under 18 years (see Appendix 2 for catch-up schedules).

Tdap is recommended (but not funded) for adult contacts of young infants, with the exception of funded Tdap vaccine for pregnant women from 28 to 38 weeks’ gestation.

Pneumococcal vaccines (PCV13 and 23PPV)

Note that there is a potential risk of apnoea with PCV13 and other scheduled vaccines in infants born before 28 weeks’ gestation. If a preterm infant had apnoeas following immunisation in hospital (6 week and/or 3-month event), readmission for the next infant immunisation and respiratory monitoring for 48 to 72 hours may be warranted,6 but do not avoid or delay immunisation.

4.2.2 Infants with congenital heart disease (CHD)Top

4.2.3 Infants with liver and renal diseaseTop

Some infants with congenital biliary or renal conditions are likely to need transplantation. An accelerated immunisation schedule for these infants is provided in Table 4.1. The aim of the accelerated schedule is to maximise protection against vaccine-preventable diseases and to deliver live viral vaccines prior to transplantation and immunosuppression.

Infants with biliary atresia may have polysplenia (functional hyposplenia) (see section 4.3.4).

Other chronic kidney diseases also warrant extra immunisations (see section 4.3.3).

Table 4.1: Accelerated immunisation schedule (funded) for infants in whom liver or kidney transplant is likely

Note: Varicella vaccine is funded for susceptible household contacts of transplant patients. Refer to the Pharmaceutical Schedule (www.pharmac.govt.nz) for the number of funded doses and any changes to funding decisions.

Age Immunisation/serology Comments
6 weeks Usual Schedule: DTaP-IPV-HepB/Hib (Infanrix-hexa), PCV13 (Prevenar 13) and RV5 (RotaTeq) Do not start earlier than age 6 weeks.
3 months Usual Schedule, plus MenCCV (NeisVac-C)  
5 months Usual Schedule, plus MenCCV (NeisVac-C)  
7 months MMR (MMR II) MMR should not be given within
1 month of predicted transplant.
Varicella (Varilrix) In general, VV should not be given within 1 month of predicted transplant but may be given at the discretion of the specialist.
Hep A (Havrix Junior)  
Anti-HBs serology If anti-HBs is negative, give a further 3 doses of monovalent
Hep B vaccine, 4 weeks apart (HBvaxPRO; use the 10 µg adult dose).
12 months PCV13 (Prevenar 13)  
MMR (MMR II) MMR should not be given within 1 month of predicted transplant.
Varicella (Varilrix) In general, VV should not be given within 1 month of predicted transplant but may be given at the discretion of the specialist.
MenCCV (NeisVac-C)  
13 months DTaP-IPV-HepB/Hib (Infanrix hexa)  
MMR (MMR II) MMR should not be given within 1 month of predicted transplant.
Hep A (Havrix Junior) If Hep A and Hep B are due at the same time, consider using combined Hep A-Hep B vaccine (Twinrix; not funded).  
24 months 23PPV (Pneumovax 23) Revaccinate once after 5 years.
MCV4-D (Menactra) 2 doses of MCV4-D, 8 weeks apart, and at least 4 weeks after last PCV13. Give a booster after 3 years, then 5-yearly.
6 months post-transplant Hep B (HBvaxPRO), plus anti-HBs serology before and 1 month after the initial Hep B series 3 doses of Hep B vaccine (5 µg). If Hep B was not previously given, and anti-HBs is negative, give 3 doses of Hep B vaccine (10 µg). If there is an inadequate immune response to the initial 3-dose Hep B series, give a further 3 doses (10 µg).
23PPV If at least 24 months old and not given pre-transplant. Revaccinate once after 5 years.
4 years Usual Schedule: DTaP-IPV (Infanrix-IPV) and MMR (MMR II) MMR can only be given if pre-transplant.
From age 9 years HPV4 or HPV9 (Gardasil or Gardasil 9) 3 doses at 0, 2 and 6 months.* Funded post-transplant. If given early, they do not require the usual Schedule doses in year 7/8 (age 11/12 years).
11 years Usual Schedule: Tdap (Boostrix)  
Annually Influenza (Influvac or Fluarix) Recommended for patients (funded) and all family members (not funded). For patients (at any age) and family members aged under 9 years, give 2 doses 4 weeks apart in the first year, and 1 dose in subsequent years.
* Individuals who started with HPV4 may complete their remaining doses with HPV4 or with HPV9 when available.

Source: Starship Children’s Health.

4.2.4 Asplenic infantsTop

No vaccines are contraindicated for infants with functional or anatomical asplenia. The usual National Immunisation Schedule should be followed, with the addition of age-appropriate pneumococcal polysaccharide, meningococcal conjugate, influenza and varicella vaccines, as discussed in section 4.3.4.

4.2.5 Infants exposed to hepatitis B, with mothers with chronic HBV infectionTop

Infants exposed to maternal hepatitis B infection require a birth dose of hepatitis B vaccine and hepatitis B immunoglobulin (HBIG) (see section 8.5.3).

4.2.6 Immune-deficient infantsTop

Diagnosis of immune deficiency is often not made before children start their immunisation schedules. However, no parenteral live virus vaccines are given on the Schedule in the first year of life. Rotavirus vaccine is an oral, live, attenuated viral vaccine, which should not be given when severe combined immune deficiency (SCID) has been diagnosed; its use in milder immune deficiency may cause prolonged shedding of the vaccine virus, but it is unlikely to harm the patient.

BCG, being a live bacterial vaccine against tuberculosis, can cause disseminated disease in certain rare immune deficiencies. In the past few years, eligibility criteria for neonatal BCG have been restricted (see chapter 20) and universal antenatal human immunodeficiency virus (HIV) screening introduced, thus reducing the risk of BCG being given to a child with an undiagnosed immune deficiency. For infants whose mothers received anti-tumour necrosis factor (anti-TNF) therapies (eg, infliximab) during pregnancy, BCG vaccination should be delayed until the infant is at least 8–9 months old.7

(See also section 4.3).

4.2.7 Infants with HIVTop

Infants with HIV infection who do not have severe immunosuppression should follow the routine Schedule and are also eligible to receive funded meningococcal, varicella and influenza vaccines, plus pneumococcal polysaccharide vaccine from age 2 years. (See the HIV discussion in section 4.3.3).

4.2.8 Other conditionsTop

All infants with the following conditions should receive the routine Schedule vaccines, plus the additional vaccines as described.

Infants with diabetes are eligible for funded influenza vaccine from age 6 months (see section 10.5); pneumococcal polysaccharide vaccine is recommended (but not funded) from age 2 years (see section 15.5).
Influenza and varicella vaccines are funded for infants with inborn errors of metabolism at risk of major metabolic decompensation (see sections 10.5 and 21.5).
Varicella vaccine is recommended for a variety of endocrine disorders – discuss with the specialist.