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Específicas, Hospital Clínico San Carlos, Madrid, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Departamento de Salud Pública y Maternoinfantil, Universidad Complutense, CIBERINFEC Ciber de Enfermedades Infecciosas, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Pediatría, Enfermedades Infecciosas y Tropicales, Hospital Universitario La Paz, CIBERINFEC Ciber de Enfermedades Infecciosas, Universidad Autónoma de Madrid, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Centro de Salud de Llanera, Asturias, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Sociedad Española de Infectología Pediátrica" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Comité Asesor de Vacunas de la AEP" "etiqueta" => "j" "identificador" => "aff0050" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso de la Sociedad Española de Infectología Pediátrica y el Comité Asesor de Vacunas de la Asociación Española de Pediatría para la vacunación en inmunodeprimidos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In recent decades, the number of people living with immunosuppression has been increasing due to their increased survival and the use of new immunosuppressive treatments for various chronic diseases. This is a heterogeneous group of patients in whom immunosuppression may result from an inborn error of immunity or secondary to a disease or immunosuppressive therapy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Depending on the cause of immunosuppression (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), the course of underlying disease and the treatments use, the level of immune impairment can be mild, moderate or severe, and it can also remain stable, vary or reverse over time.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Immunosuppressed individuals are at increased risk of contracting vaccine-preventable diseases that can cause exacerbations of underlying disease and have a more severe course compared to immunocompetent individuals. Therefore, it is of utmost importance to optimise vaccination in this population.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the context of immunosuppression, the immune response to vaccines is suboptimal, so vaccination should be performed at the earliest opportunity to achieve the best possible response, preferably at the time of diagnosis, but ensuring that necessary treatment is not deferred. However, misinformation and fears concerning the safety of vaccines or the course of underlying disease frequently result in undervaccination or delayed vaccination in immunosuppressed children.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This document, developed through the critical review of relevant scientific information obtained through a non-systematic review of published research and expert consensus documents, provides guidelines to develop a personalised vaccination schedule for each patient. It is divided in 6 sections: (a) general recommendations, (b) vaccination of haematopoietic stem cell transplant (HSCT) and solid organ transplant (SOT) recipients, (c) vaccination of children with innate errors of immunity, (d) vaccination of oncological patients, (e) vaccination of patients with chronic or systemic diseases and (f) vaccination of immunosuppressed children who plan to travel.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">General recommendations for vaccination of immunosuppressed children and adolescents</span><p id="par0025" class="elsevierStylePara elsevierViewall">With the exceptions allowed for special situations, immunosuppressed children and adolescents should receive all the vaccines in the routine immunization schedule in addition to those recommended to the specific group to which they belong. The annual vaccine against the seasonal flu, the pneumococcal vaccine and the SARS-CoV-2 vaccine are all recommended for immunosuppressed children in general, to be given according to the current schedule for risk groups.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Inactivated vaccines do not pose a threat to the health of immunosuppressed patients, although the immunogenicity will not be optimal and they may require additional primary series and/or booster doses.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Live attenuated vaccines (measles, mumps and rubella [MMR], varicella, rotavirus, attenuated influenza, oral typhoid fever, yellow fever, bacillus Calmette–Guérin [BCG] and oral polio) are contraindicated in severely immunosuppressed patients (see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) due to the risk of replication and development of disease by vaccine strains. Recent data have shown that these vaccines can be safe and immunogenic if the markers of humoral and cellular immunity are within specific ranges, but further studies are required to confirm the recommendation of these vaccines under these circumstances.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In the case of elective immunosuppression, administration of all indicated vaccines with an accelerated schedule is recommended before initiation of immunosuppression, administering live attenuated vaccines at least 4 weeks before and inactivated vaccines at least two weeks before. After completion of treatment, the recommended interval prior to vaccination ranges from 3 months to 2 years depending on the specific situation and type of vaccine. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarises the general recommendations for vaccination of immunosuppressed children and adolescents.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Individuals vaccinated at intervals other than those recommended or during treatment should be considered as potential nonresponders and the need for a booster dose assessed, performing serologic tests serving as correlates of protection, when available, a month after the administration of the most recent dose to guide revaccination, and considering the use of passive immunoprophylaxis and/or chemoprophylaxis in the case of exposure of individuals at risk.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Caregivers and household members should be fully and correctly vaccinated, with particular emphasis on the MMR, varicella, seasonal influenza and SARS-CoV-2 vaccines. The oral vaccines against poliovirus and <span class="elsevierStyleItalic">Salmonella typhi</span> Ty21 are contraindicated. The intranasal live attenuated influenza vaccine can be administered to the close contacts of immunosuppressed patients with the exception of those who have undergone HSCT in the past 2 months, with graft versus host disease (GvHD) or with severe combined immunodeficiency (SCID).</p><p id="par0055" class="elsevierStylePara elsevierViewall">As a precaution, immunosuppressed individuals should avoid contact with the faecal material of an infant vaccinated against rotavirus for 4 weeks following vaccination and, in the case of close contacts who develop a rash after vaccination against varicella, avoid contact with the lesions.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Vaccination in paediatric haematopoietic stem cell and solid organ transplant recipients</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Haematopoietic stem cell transplant recipients (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>)<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–12</span></a></span><p id="par0060" class="elsevierStylePara elsevierViewall">Paediatric HSCT recipients experience immunosuppression to a degree that depends on the underlying disease and type of transplant, and is most severe and lasting in the case of allogeneic transplants. The changes in immunity result in decreased vaccine immunogenicity, so some time must be allowed to pass after transplantation to implement an adapted immunization schedule to achieve complete vaccination.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Vaccination against pneumococcal disease should start from 3 months from HSC transplantation with conjugate vaccines, administering 3 doses at least 1 month apart and a fourth dose 6 months after the third. In addition, the remaining conjugate vaccines should be administered starting from 6 months post transplantation, including the tetanus toxoid and reduced diphtheria toxoid and acellular pertussis (Tdap), inactivated poliovirus (IPV), hepatitis B (HB), <span class="elsevierStyleItalic">Haemophilus influenzae</span> type b (Hib), meningococcal B/ACWY and influenza vaccines. During the flu season, the influenza vaccine can be administered from 4 months post-HSCT, and if the patient has GvHD, a booster can be given 4–8 weeks later. Immunization against human papillomavirus with 9-valent vaccine (HPV9, 3 doses) is recommended starting at age 9 years.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The MMR and varicella vaccines can be administered from 24 months (2 doses at least 1 month apart) as long as the patient does not have GvHD, is not receiving immunosuppressant drugs, has not received immunoglobulin replacement therapy in the past few months and the CD4 count is greater than 200/mm<span class="elsevierStyleSup">3</span>.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Solid organ transplant recipients<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9,11,12</span></a></span><p id="par0075" class="elsevierStylePara elsevierViewall">It is essential to vaccinate the patient as fully as possible before solid organ transplantation, even by implementing an accelerated schedule. After transplantation, the recipient will be immunosuppressed so the response to inactivated vaccines will not be optimal and live attenuated vaccines will be contraindicated.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Vaccination before solid organ transplantation should stop at least 4 weeks prior in the case of live vaccines and 2 weeks prior in the case of inactivated vaccines. Vaccination can resume 6 months after transplantation.</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Before transplantation</span><p id="par0085" class="elsevierStylePara elsevierViewall">The MMR and varicella vaccines can be administered earlier than scheduled starting from age 6 months. Administration of the HB and hepatitis A (HA) vaccines is indicated, and assessment of immunity after vaccination is recommended (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, notes 3 and 4). Ensuring correct vaccination against pneumococcal disease is essential. Vaccination against huma papillomavirus with 3 doses of HPV9 is indicated for any age.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">After transplantation (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>)</span><p id="par0090" class="elsevierStylePara elsevierViewall">Live vaccines (MMR, varicella, rotavirus, yellow fever, oral typhoid fever) are contraindicated. In the case of inactivated vaccines, even if the patient is fully vaccinated, it is recommended to administer booster doses of IPV IPV, DTaP/Tdap, pneumococcal vaccine and SARS-CoV-2 vaccine. Administration of the influenza vaccine is recommended from 1 month post transplantation. The patient should be given the pneumococcal vaccine with the highest valency available. Performance of hepatitis A and B immunity tests is recommended after post-SOT (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) and every 2 years thereafter, administering a booster dose if the test result is negative.</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Vaccination of children with inborn errors of immunity</span><p id="par0095" class="elsevierStylePara elsevierViewall">Inborn errors of immunity (IEIs) are a heterogeneous group of diseases associated with a growing number of gene variants<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> and with a variable risk of infection, so vaccination must be individualised in affected patients. For practical purposes, IEIs are classified into 3 groups: defects in adaptive immunity, defects in innate immunity and IEIs associated with characteristic phenotypes or syndromic immunodeficiencies.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Inborn errors of immunity carry an increased risk of vaccine-preventable diseases and a reduced immune response, both in duration and intensity. Nevertheless, there is evidence of the protective effect of vaccination, associated with a decrease in mortality and the incidence of complications,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which is why these patients usually require booster doses.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Live attenuated vaccines (viral or bacterial) carry a risk of dissemination in patients with defects in cell-mediated immunity,<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> and while suspicion of an IEI is not sufficient reason to delay vaccination, live attenuated vaccines are contraindicated until the level of immune impairment is established.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Inactivated or subunit vaccines are safe and can be effective. In patients with IEIs requiring immunoglobulin replacement therapy, live attenuated viral vaccines should not be administered for the next 3–11 months due to the interference of the treatment with the vaccine response.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Considering the above, children IEIs generally require an expanded vaccination schedule,<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a> especially for protection against encapsulated bacteria: pneumococcus, meningococcus (B/ACWY) and Hib, and from 6 months, annual vaccination against influenza with inactivated quadrivalent vaccine and against SARS-CoV-2 in adherence with current recommendations.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> It is also essential to promote the vaccination of household members and the general population.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> presents an approximate vaccination schedule for the most frequent IEIs.</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Vaccination of immunosuppressed children who are not transplant recipients: oncological patients</span><p id="par0125" class="elsevierStylePara elsevierViewall">Immunosuppression in oncological paediatric patients persists for months after completion of treatment, affecting the immunogenicity of vaccines administered before, during or soon after chemotherapy.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,20,21</span></a> In addition, some patients may have anatomic or functional asplenia (radiation therapy to the abdomen, GvHD). The evidence regarding vaccination in the context of novel immunotherapies is still insufficient.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20,21</span></a></p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">General principles for vaccination of children managed with chemotherapy</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Before chemotherapy</span><p id="par0130" class="elsevierStylePara elsevierViewall">If feasible, getting vaccination up to date according to the routine immunization schedule is recommended, administering inactivated vaccines at least 2 weeks before and attenuated vaccines at least 4 weeks before initiation of chemotherapy.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">During chemotherapy</span><p id="par0135" class="elsevierStylePara elsevierViewall">Vaccines in the routine immunization schedule should not be administered during intensive chemotherapy. The response to inactivated vaccines is very small (vaccination would be considered to have failed) and attenuated vaccines are contraindicated.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In children receiving maintenance treatment for lymphoblastic leukaemia, annual vaccination against influenza is recommended from age 6 months. The guidelines of the European Conference on Infections in Leukaemia also recommend a PCV booster dose,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> although the immune response may be suboptimal and administration of another dose is necessary after treatment has been completed.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22,23</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">After chemotherapy</span><p id="par0145" class="elsevierStylePara elsevierViewall">Repeating primary vaccination with vaccines the child has already received is not necessary. In fully vaccinated children, administration of a booster dose of previously received vaccines is recommended, after which vaccines should be administered according to the routine immunization schedule based on the age of the patient.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,21</span></a> If the vaccination was not up to date at initiation of chemotherapy, catch-up vaccination will be the first step. The schedule for catch-up vaccination, including the number of doses of each vaccine, the minimum age for administration and the minimum intervals between doses, can be consulted in the tables published by the Advisory Committee on Vaccines of the AEP (CAV-AEP).<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Inactivated vaccines should be administered between 3 and (preferably) 6 months after completion of chemotherapy, while the administration of attenuated vaccines should be deferred to 6–12 months after (preferably 12). In regimes that include anti-B cell antibodies, an interval of 6–12 months is recommended before administration of any vaccine.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,21</span></a> Recent data show that children with lymphoblastic leukaemia could receive the pneumococcal conjugate vaccine right after completing treatment, as the response is similar to that of those vaccinated 6 months after.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Early administration of this vaccine could be contemplated, especially in children who missed vaccination during maintenance chemotherapy.</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Specific recommendations for vaccination of oncological patients</span><p id="par0155" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0160" class="elsevierStylePara elsevierViewall">Pneumococcal: PCV15 + PCV23 sequence, or PCV20 exclusively.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Influenza: annual inactivated vaccines, at least the 3 seasons following completion of chemotherapy.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">SARS-CoV-2: schedule depending on age and type of vaccine.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">HPV9: recommended from age 9 years.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">The use of live attenuated vaccines is not recommended in patients treated with tyrosine-kinase inhibitors or ruxolitinib.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></li></ul></p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Vaccination of children with chronic diseases</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Vaccination of children with autoimmune or autoinflammatory diseases receiving immunosuppressive treatment<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25–29</span></a></span><p id="par0185" class="elsevierStylePara elsevierViewall">The earliest recommendations of the European Alliance of Associations for Rheumatology (EULAR) were developed in 2011, and many were extrapolated from the adult literature due to the low quality of the studies conducted in children. Since then, the evidence on the safety and immunogenicity of vaccines has doubled.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">General recommendations</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">If possible, vaccines should be administered 2–4 weeks before initiation of immunosuppressive therapy (especially in the case of B-cell depleting therapies), but necessary treatment should never be deferred. However, the interval may vary depending on the type of drug (see Table 14.3 of the CAV-AEP at <a href="https://vacunasaep.org/documentos/manual/cap-14#7">https://vacunasaep.org/documentos/manual/cap-14#7</a>)</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Vaccination during the inactive phase of disease/remission is advisable, and it should not be delayed out of fear of triggering an exacerbation, as there is no evidence of such an association.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">All immunosuppressed patients must adhere to the routine vaccination schedule and travel vaccination requirements, with the exception of live attenuated vaccines.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Inactivated vaccines can be administered to patients receiving corticosteroids or disease-modifying antirheumatic drugs (DMARDs).</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">Live attenuated viral vaccines are contraindicated in patients with treatments resulting in high-level immunosuppression (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), with the exception of MMR booster doses and the varicella vaccine, whose administration can be contemplated on a case-by-case basis under specific circumstances.</p></li></ul></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Specific recommendations (based on the 2021 EULAR recommendations)<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></span><p id="par0220" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall">Vaccination against tetanus according to current general recommendations; passive immunization is recommended for patients who have received B cell-depleting therapy in the past 6 months in whom administration of tetanus toxoid is indicated.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall">Administration of HPV9 should be considered in previously unvaccinated patients with systemic lupus erythematosus or inflammatory bowel disease (3 doses if the patient receives immunosuppressive therapy).</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0235" class="elsevierStylePara elsevierViewall">Administration of the MMR booster dose could be considered on a case-by-case basis, after assessment by the specialist in charge, in patients receiving methotrexate (MTX) at immunomodulating doses (A-level recommendation) or low-dose steroids, anti-TNFα, anti-IL-1 or anti-IL-6 (C-level recommendation).</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0240" class="elsevierStylePara elsevierViewall">Administration of the varicella vaccine could be considered on a case-by-case basis, after assessment by the specialist in charge, in naïve patients receiving methotrexate (MTX) at immunomodulating doses A-level recommendation) or low-dose steroids, anti-TNFα, anti-IL-1 or anti-IL-6 (D-level recommendation).</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0245" class="elsevierStylePara elsevierViewall">Vaccination against yellow fever should be avoided in any patient receiving immunosuppressive therapy (D-level recommendation)</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0250" class="elsevierStylePara elsevierViewall">Vaccination against hepatitis A is recommended in patients treated with hepatotoxic immunosuppressive drugs (MTX or tocilizumab).</p></li></ul></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Kidney and liver diseases<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26,31</span></a></span><p id="par0255" class="elsevierStylePara elsevierViewall">Vaccination against <span class="elsevierStyleBold">hepatitis B</span> is essential, in addition to monitoring of the vaccine response. Vaccination against <span class="elsevierStyleBold">hepatitis A</span> is also indicated, with the standard schedule or alternatively with the combination vaccine (A + B) if a booster dose of HB is required. In the absence of immunosuppression, vaccination against <span class="elsevierStyleBold">measles and varicella</span> is recommended as soon as possible after diagnosis.</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Cardiovascular and respiratory diseases<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a></span><p id="par0260" class="elsevierStylePara elsevierViewall">This includes children with congenital heart diseases (cyanotic diseases, associated with heart failure or haemodynamic changes), pulmonary hypertension, bronchopulmonary dysplasia, cystic fibrosis, bronchiectasis and moderate to severe asthma. Vaccination against <span class="elsevierStyleBold">varicella</span> according to the routine schedule is recommended, with the qualification that in patients treated with salicylates it is considered preferable to discontinue treatment for 6 weeks after the administration of the vaccine (if not possible, the patient should still be vaccinated, as there have been no reports of Reye syndrome associated with the vaccine-type virus).</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Neurologic diseases<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a></span><p id="par0265" class="elsevierStylePara elsevierViewall">No vaccines are contraindicated for children with epilepsy. In fact, the use of the vaccine with acellular pertussis has been found to significantly decrease the incidence of febrile seizures associated with the diphtheria, tetanus and whole-cell pertussis vaccines. If the patient receives hepatotoxic drugs, such as valproic acid, vaccination against hepatitis A is recommended.</p><p id="par0270" class="elsevierStylePara elsevierViewall">However, in the presence of a progressive, unstable or unspecified encephalopathy, the administration of vaccines that could destabilize the patient (like the pertussis vaccine) should be deferred. In the case of neurological autoimmune or inflammatory disease in which there are grounds to suspect an association with a given vaccine, no other doses of the vaccine should be administered.</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Genetic disorders (Down syndrome)<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a></span><p id="par0275" class="elsevierStylePara elsevierViewall">Annual vaccination against influenza and vaccination against pneumococcal disease (with PCV15 + PPSV23 or PCV20 exclusively) and hepatitis A is recommended for children with Down syndrome.</p><p id="par0280" class="elsevierStylePara elsevierViewall">For children with other genetic disorders, specific vaccination requirements need only be assessed if there are chronic immune comorbidities.</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Haemoglobin disorders<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a></span><p id="par0285" class="elsevierStylePara elsevierViewall">Children with haemoglobin disorders manifesting with functional hyposplenism must be vaccinated against pneumococcal disease (with PCV15 + PPSV23 or PCV20), Hib and meningococcal disease (Men ACWY + booster dose at 5 years and Men B with booster doses 1 year after completion of the primary series and every 5 years thereafter), and also against hepatitis (A and B) due to the increased risk of liver disease. It is important to consider the recommended intervals (6–7 months) between the transfusion of blood products and the administration of attenuated vaccines. In Spain, as long as there is no outbreak of measles, mumps or rubella, changes to the immunization schedule are not indicated if the patient is going to be treated with hydroxyurea in the first year of life.</p><p id="par0290" class="elsevierStylePara elsevierViewall">Patients with beta thalassaemia <span class="elsevierStyleItalic">minor</span> or sickle cell trait should receive the same vaccines as the general population.</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Cochlear implant<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a></span><p id="par0295" class="elsevierStylePara elsevierViewall">Due to the risk of developing meningitis and otitis media, vaccination against pneumococcal disease is particularly recommended (with PCV15 + PPSV23 or PCV20), in addition to Hib and annual vaccination against influenza.</p><p id="par0300" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a> presents an approximate vaccination schedule for immunosuppressed children with chronic diseases.</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Vaccination of immunosuppressed children who plan to travel</span><p id="par0305" class="elsevierStylePara elsevierViewall">Before traveling, immunosuppressed children should have their vaccines up to date, and it is a good time to administer upcoming doses, possibly earlier than established in the vaccination schedule, if their immune status allows it.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32–39</span></a> Individualised guidance must be provided sufficiently in advance to ensure that administered vaccines are effective. Thus, it is recommended that the child make a visit between 4 and 6 weeks prior to the departure. If it can be avoided, immunosuppressed children aged less than 2 years should not travel.</p><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Specific vaccination of travellers<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32–39</span></a></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Routine/universal vaccines</span><p id="par0310" class="elsevierStylePara elsevierViewall">Those recommended in the routine vaccination schedule for children of the traveller’s age. If the child’s vaccination is not up to date, the missing doses will be administered before travel. If the child is to travel to a country endemic for a disease against which the child has not been vaccinated, such as measles or varicella, the vaccine will be administered earlier than scheduled as long as it is possible.</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Specific vaccines for travellers (see <a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>)</span><p id="par0315" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">•</span><p id="par0320" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleUnderline">Mandatory</span>:</span> depending on the destination, type of travel and age. It includes those required by receiving countries for entry: yellow fever, meningococcal and poliovirus. The authorities of countries with specific requirements will expect travellers to carry an International Certificate of Vaccination or Prophylaxis correctly recording the received vaccinations.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">•</span><p id="par0325" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleUnderline">Recommended depending on travel</span>:</span> depending on the destination, the risk assessment of the child and the type of travel.</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></li></ul></p></span></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Requirements based on the level of immunosuppression<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32–39</span></a></span><p id="par0330" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a> presents the specific recommendations for vaccination of immunosuppressed children who plan to travel.</p><elsevierMultimedia ident="tbl0040"></elsevierMultimedia></span></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Funding</span><p id="par0335" class="elsevierStylePara elsevierViewall">This research project did not receive specific financial support from funding agencies in the public, private or not-for-profit sectors.</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conflicts of interest (last 5 years)</span><p id="par0340" class="elsevierStylePara elsevierViewall">Irene Rivero Calle has collaborated in educational activities funded by GlaxoSmithKline, MSD, Pfizer and Sanofi Pasteur, as a researcher in vaccine clinical trials for Abbot, AstraZeneca, Enanta, Gilead, GlaxoSmithKline, HIPPRA, Janssen, Medimmune, Merck, Moderna, MSD, Novavax, Pfizer, Reviral, Roche, Sanofi and Seqirus; and as a consultant in GlaxoSmithKline, MSD, Pfizer and Sanofi advisory boards.</p><p id="par0345" class="elsevierStylePara elsevierViewall">Teresa del Rosal has received fees for participation in conferences and from research grants from MSD, funding to attend educational activities from Pfizer and collaborated as researcher in clinical trials for GSK, Janssen and MSD, for which the institution she is affiliated with received fees.</p><p id="par0350" class="elsevierStylePara elsevierViewall">Elisa Garrote has collaborated in educational activities funded by GlaxoSmithKline, MSD, Pfizer and Sanofi, as a researcher in vaccine clinical trials for de GlaxoSmithKline, and as a consultant in GlaxoSmithKline and MSD advisory boards.</p><p id="par0355" class="elsevierStylePara elsevierViewall">Esmeralda Núñez has collaborated in educational activities funded by Pfizer.</p><p id="par0360" class="elsevierStylePara elsevierViewall">María Luisa Navarro has collaborated in educational activities funded by Gilead, GlaxoSmithKline, Janssen, MSD, Pfizer and ViiV, as a consultant in Abbott, AstraZeneca, Novartis, Pfizer and ViiV advisory boards and in clinical trials funded by GlaxoSmithKline, Pfizer, Roche, MSD, Sanofi and Pfizer.</p><p id="par0365" class="elsevierStylePara elsevierViewall">José Tomas has received fees for participation in conferences from Gilead, GSK, ViiF and Pfizer. He has received grants or funding to attend training workshops from BioMerieux, Gilead and Pfizer. He has received fees as a consultant for Pfizer, GSK and ViiF. He has collaborated as the principal investigator of the centre in clinical trials of Pfizer, GSK and Janssen, for which his institution collected fees.</p><p id="par0370" class="elsevierStylePara elsevierViewall">Cristina Calvo has received fees for participation in conferences from MSD and Pfizer. She has received research grants/funding from MSD and BioMerieux. She has received fees as a consultant for Sanofi. She has participated as a researcher in clinical trials conducted by Abbott, MSD, Pfizer, Janssen, GSK and Allergan, for which her institution collected fees.</p><p id="par0375" class="elsevierStylePara elsevierViewall">Francisco Álvarez García has received funding to attend domestic educational activities. He has participated in educational activities funded by Alter, AstraZeneca, GSK, Pfizer, MSD and Sanofi and served as a consultant in GSK, Pfizer, MSD and Sanofi advisory boards.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres2054693" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1754412" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2054692" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1754413" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "General recommendations for vaccination of immunosuppressed children and adolescents" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Vaccination in paediatric haematopoietic stem cell and solid organ transplant recipients" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Haematopoietic stem cell transplant recipients (Table 3)" ] 1 => array:3 [ "identificador" => "sec0025" "titulo" => "Solid organ transplant recipients" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Before transplantation" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "After transplantation (Table 4)" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Vaccination of children with inborn errors of immunity" ] 8 => array:3 [ "identificador" => "sec0045" "titulo" => "Vaccination of immunosuppressed children who are not transplant recipients: oncological patients" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0050" "titulo" => "General principles for vaccination of children managed with chemotherapy" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Before chemotherapy" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "During chemotherapy" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "After chemotherapy" ] ] ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Specific recommendations for vaccination of oncological patients" ] ] ] 9 => array:3 [ "identificador" => "sec0075" "titulo" => "Vaccination of children with chronic diseases" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Vaccination of children with autoimmune or autoinflammatory diseases receiving immunosuppressive treatment" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "General recommendations" ] 2 => array:2 [ "identificador" => "sec0090" "titulo" => "Specific recommendations (based on the 2021 EULAR recommendations)" ] 3 => array:2 [ "identificador" => "sec0095" "titulo" => "Kidney and liver diseases" ] 4 => array:2 [ "identificador" => "sec0100" "titulo" => "Cardiovascular and respiratory diseases" ] 5 => array:2 [ "identificador" => "sec0105" "titulo" => "Neurologic diseases" ] 6 => array:2 [ "identificador" => "sec0110" "titulo" => "Genetic disorders (Down syndrome)" ] 7 => array:2 [ "identificador" => "sec0115" "titulo" => "Haemoglobin disorders" ] 8 => array:2 [ "identificador" => "sec0120" "titulo" => "Cochlear implant" ] ] ] 10 => array:3 [ "identificador" => "sec0125" "titulo" => "Vaccination of immunosuppressed children who plan to travel" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0130" "titulo" => "Specific vaccination of travellers" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0135" "titulo" => "Routine/universal vaccines" ] 1 => array:2 [ "identificador" => "sec0140" "titulo" => "Specific vaccines for travellers (see Table 7)" ] ] ] 1 => array:2 [ "identificador" => "sec0145" "titulo" => "Requirements based on the level of immunosuppression" ] ] ] 11 => array:2 [ "identificador" => "sec0150" "titulo" => "Funding" ] 12 => array:2 [ "identificador" => "sec0155" "titulo" => "Conflicts of interest (last 5 years)" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-10-02" "fechaAceptado" => "2023-11-13" "PalabrasClave" => array:2 [ "en" =>