Browser Not Supported

It looks like you're using an outdated browser. To view this site properly, please switch to a more modern browser such as Chrome,Firefox, or Edge.

Immunisations and Cardiac Infants

Date last published:

The incidence of vaccine preventable diseases in New Zealand is relatively high and some (e.g. pertussis, influenza, measles) pose a significant risk to infants with already impaired cardiac function.

This document is only valid for the day on which it is accessed. Please read our .
Cardiology

see National Immunisation Schedule.

The incidence of vaccine preventable diseases in New Zealand is relatively high¹ and some (e.g. pertussis, influenza and measles) pose a significant risk to infants with already impaired cardiac function. It is also known that infants and children in hospital are at risk of missing their routine immunisations because either they do not see their primary care provider or they miss opportunistic immunisation when in secondary or tertiary care.¹⁰

Routine immunisations on the national schedule should be given to infants with cardiac conditions, but those who have cyanosis or failure and children with Down Syndrome, are eligible for the extended pneumococcal immunisation programme ( PCV13 and 23PPV - see Health NZ Immunisation Handbook https://www.tewhatuora.govt.nz/for-health-professionals/clinical-guidance/immunisation-handbook/17-pneumococcal-disease: Table 17.3: Extended pneumococcal immunisation for children aged under 5 years – funded PCV13 and 23PPV indications and schedules. Most children with cardiac conditions are also eligible for a free annual influenza vaccination⁹ and COVID-19 vaccines (see Starship Guideline on COVID-19 vaccination in children).

Restrictions, cautions and contraindications

1. Children with Heterotaxy Syndrome

An individual decision needs to be made for each child. See recommended vaccination schedule for the Asplenic neonate - Starship Splenectomy Guideline.

See Health NZ Immunisation Handbook Table 4.5: Additional vaccine recommendations for infants and children aged under 18 years with functional or anatomical asplenia.

2. Children with the potential for reduced immune competence (e.g Children with 22 q.11.2 deletion syndrome)

Live vaccines are contraindicated for all individuals with T lymphocyte-mediated immune deficiencies and combined B- and T-lymphocyte disorders.⁹ However, no parenteral live virus vaccines are given on the Schedule in the first year of life.

All infants with potential reduced immune competence should have their immunological status assessed in consultation with paediatric immunology to determine vaccine safety prior to all live vaccines including Rotavirus and BCG. Rotavirus vaccine is an oral, live, attenuated viral vaccine which is contraindicated in severe combined immune deficiency (SCID)9 but is considered safe in milder immune deficiencies. BCG is given to newborns and infants with epidemiological risk and is contraindicated in any immune deficiency or infants under evaluation.

3. Children who have received blood products/immunoglobulin

Below are the current recommendations for deferment of live parenteral vaccines after receipt of blood products. Note that the live vaccines will not cause harm if given earlier than this, but the immune response may be suboptimal, leaving a patient at risk for the relevant disease(s).

In an outbreak situation (e.g. measles) immunisation may be given at any time as the benefit could outweigh the potential impaired response. If given earlier then subsequent serotesting or repeating live vaccine dose at an appropriate time interval can be done.

3a. Children who have received intravenous immunoglobulin (e.g. for myocarditis or Kawasaki disease)

should not have any parenteral live attenuated viral immunisations (MMR, Varicella) for 11 months post treatment.⁸, ⁹See Health NZ Immunisation Handbook https://www.tewhatuora.govt.nz/for-health-professionals/clinical-guidance/immunisation-handbook/appendix-6-passive-immunisation Table A6.1: Suggested intervals between immunoglobulin and blood product administration or blood transfusion and MMR or varicella vaccination. This does not apply to oral Rotavirus immunisation.

3b. Children who have received whole blood transfusion (including during surgery on bypass)

should not have any parenteral live attenuated virus immunisations (MMR, Varicella) for seven months. See Health NZ Immunisation Handbook https://www.tewhatuora.govt.nz/for-health-professionals/clinical-guidance/immunisation-handbook/appendix-6-passive-immunisation Table A6.1: Suggested intervals between immunoglobulin and blood product administration or blood transfusion and MMR or varicella vaccination. This does not apply to oral Rotavirus immunisation. Note: receipt of washed red blood cells does not require any stand down time before live attenuated vaccines are given.

3c. Children who have received other immunoglobulin such as VZIG or human Normal Immunoglobulin

See Health NZ Immunisation Handbook https://www.tewhatuora.govt.nz/for-health-professionals/clinical-guidance/immunisation-handbook/appendix-6-passive-immunisation Table A6.1: Suggested intervals between immunoglobulin and blood product administration or blood transfusion and MMR or Varicella vaccination. This does not apply to oral Rotavirus immunisation.

4. Children with myocarditis

Active cardiac inflammation is a contraindication to receipt of COVID-19 vaccines. If myocarditis or pericarditis arose as a consequence of COVID-19 vaccination, further doses should be deferred and consideration given to alternative vaccine formulation if more doses needed. See Starship guideline on COVID-19 post-vaccination pericarditis/myocarditis.

5. Children on low-dose aspirin

It has previously been suggested that low dose aspirin be avoided in children following chicken pox (varicella) immunisation due to theoretical risk of Reyes syndrome. However, this risk is small compared to the documented risk of shunt thrombosis without low dose aspirin treatment¹¹,¹². The combination of natural varicella infection (chicken pox) and aspirin use in anti-inflammatory (or "high") doses has been associated with Reye's syndrome, but association has not been demonstrated with antiplatelet ("low dose") aspirin treatment¹³.

We therefore recommend
1. There is no cardiac contraindication to Varicella immunisation in all children once they reach an appropriate age.
2. Low dose Aspirin should be continued in all patients who are taking aspirin to maintain shunt patency

6. Children on corticosteroids

See Health NZ Immunisation Handbook Table 4.1: Guidelines for live vaccine administration for individuals receiving corticosteroid agents

7. Immunisation around the time of cardiac surgery

  • Routine immunisations should be withheld one week prior to surgery and 4-6 weeks following cardiac surgery.

  •  Live vaccines (e.g. MMR) should be withheld for seven months following bypass surgery or any other blood transfusion⁸,⁹ (except washed red blood cells). although this can be reconsidered in the face of community outbreaks, for example measles: the vaccine will not harm but the response to it may be blunted because of circulating passive antibody. This delay does not apply to Rotavirus, which should follow routine immunisation schedule of 6 weeks and 3 months. See Health NZ Immunisation Handbook https://www.tewhatuora.govt.nz/for-health-professionals/clinical-guidance/immunisation-handbook/appendix-6-passive-immunisation Table A6.1: Suggested intervals between immunoglobulin and blood product administration or blood transfusion and MMR or varicella vaccination.

8. Infants at risk for deterioration following immunisations.

Some infants may have an increased risk of deterioration or collapse following immunisation, as outlined below:

  • Infants with a complex single ventricle defect or shunt dependent lesions may have an increased risk of systemic decompensation post immunisations.

  • Infants who have had the Norwood procedure are known to have a significant incidence of interval mortality attributable in part to sudden changes in systems and pulmonary vascular resistance2. While there is as yet little clear evidence linking immunisation and deterioration/collapse in post Norwood infants, concern has been raised which it seems prudent to consider5,6,7

  • In addition, premature and/or low birth weight infants prone to pulmonary hypertensive episodes are well documented to develop apnoea, bradycardia and desaturation following immunisations up to 72 hours after administration.3,4 Also infants who have had previous reactions to immunisation.

Administration of immunisations to at risk infants

At risk infants do not necessarily need to be in hospital for immunisations, however it is recommended that monitoring requirements for infants identified as at risk are discussed with the infant's specialist prior to vaccination.

As a precautionary measure, some at risk infants may require hospital admission for observation OR close parental monitoring at home for 48-72 hours after vaccination events.

Single ventricle infants, in particular those who have undergone the Norwood procedure for HLHS, should have a clinical review prior to administration of any vaccines to ensure they are meeting single ventricle home monitoring criteria to assess risk and to identify safe place for administration.

Once discussed and deemed safe, these infants may be given their immunisations in the community. Families should be counselled to observe the child closely for 48-72 hours for respiratory distress, cyanosis or general deterioration. If there is deterioration the infant should present to hospital for immediate review.

There should be a low threshold for admission of these infants if there is parental concern. Note: these families must have direct access to emergency services over this time period (i.e. emergency phone access, transport, reasonable travelling distance to hospital) - if there is concern about ability to access emergency services then admission to hospital over that time should be considered.

Outside these restrictions, routine immunisations can be given routinely in the community.

In 2023 Meningococcal B vaccine was introduced on the NIS. This is a more reactogenic vaccine than other infant vaccines. Prophylactic paracetamol is recommended to be given up to 30 minutes prior to or immediately after MenB (Bexsero) vaccination and give up to two further doses four to six hours apart for children aged under 2 years. Ibuprofen may be given as an alternative to paracetamol six to eight hourly. For high risk infants, if practical, MenB vaccine doses could be given a few days apart from other infant vaccines to reduce the risk of febrile decompensation. See See New Zealand Immunisation Schedule for use in secondary care from IMAC for alternative schedule for MenB.

Prevention and management of decompensation
Common immunisation reactions of fever and irritability in moderate to high risk infants may lead to desaturation, apnoeas and bradycardia. Advice should be given about the use of paracetamol and cooling measures for infants in the event of fever. In the event of desaturation or other signs of decompensation, oxygen saturations, respiratory and heart rate should be monitored and oxygen available.

Immunisation of household and close contacts

Managing family risk / advice to family members
In order to reduce the incidence of infection in these infants, the immunisation status of family members (including siblings) in close contact with them should be ascertained and vaccination encouraged.

Influenza: Infant/child is eligible for free annual influenza vaccination. Annual influenza vaccination of household contacts, including children, should be encouraged but is not funded unless the person has an underlying medical condition.

Pertussis: Ensure siblings are up to date with routine immunisations. Pregnant mothers are recommended to receive free Boostrix (Tdap) afrom 16 weeks gestation of every pregnancy, preferably in the second trimester to protect both the mother and her infant from pertussis. Parents and grandparents can get Tdap (boostrix) with the GP.

Varicella: children should receive varicella vaccine at 15 months of age, as per National Immunisation Schedule. Recommend varicella vaccine for all non-immune family members (not funded unless the child is on or likely to go on immune suppressant therapy, or undergo transplant).

Covid-19: encourage immunisation of household according to national recommendations - eligibility for boosters varies by age and underlying comorbidities - see Health NZ Immunisation Handbook Recommended Immunisation schedule for COVID-19.

See New Zealand Immunisation Schedule for use in secondary care from IMAC

 

Tools