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IMMUNIZATION OF THE CHILD WITH CANCER: PASSIVE IMMUNIZATION

The use of passive immunization is well established for certain pathogens, including measles, hepatitis A, hepatitis B, and varicella. Due to possible loss of immunity while patients are receiving chemotherapy and the potential for exposure, it may be worthwhile to check yearly titers. Most of the recommendations that follow are from the American Academy of Pediatrics Red Book.

A. Measles

  1. Immune-compromised patients who are exposed to measles should receive immune globulin prophylaxis, even if previously immunized. The efficacy of immune globulin within 6 days of exposure in preventing serious complications in patients with cancer is not clear, but it is likely to be beneficial.
  2. Recommendations

a.     Immune globulin 0.5 ml/kg intramuscular (IM) (maxi-

mum dose 15 mL) should be given within 6 days of

exposure to measles. (Note that this dose is higher than

that recommended for immune-competent individuals.)

b.     Combined prophylaxis with a live virus vaccine is contraindicated in immune-compromised children, but

recommended in immune-competent contacts (sib-

lings, other family members).

B.     Hepatitis B

Administration of hepatitis B immune globulin (HBIG) effectively prevents hepatitis B for patients with a percutaneous or mucosal exposure or for household contact with a chronic HBsAg carrier. Vaccination after exposure is highly effective when combined with passive immunization in the prevention of disease, especially if the vaccine series begins within 7 days of exposure.

Recommendations

a.     Combined prophylaxis with HBIG and HBV is recommended for the unvaccinated child or for the child

with a documented negative titer despite previous

vaccination.

b.     For unvaccinated children, the dose of HBIG is 0.06

mL/kg IM (maximum dose 5 mL), to be given within 24

hours of exposure.

c.     For vaccinated children with either unknown or negative titers, the dose of HBIG is 0.5 mL IM. For the child

with a documented positive titer, HBIG is not indicated.

C.     Hepatitis A

Immune globulin can prevent clinical disease resulting from hepatitis A virus in exposed susceptible individuals when given within 14 days of exposure.

Recommendation

The dose of immune globulin is 0.02 mL/kg (maximum dose 5 mL) as soon as possible after exposure.

D.     Varicella

1. Exposure to varicella is defined as a continuing household exposure to someone with active varicella or having been in the same room with an individual who is in the contagious state (i.e., 1-2 days before and 5 days after the eruption of vesicles) for at least 1 hour.

Varicella-zoster immune globulin (VZIG) is highly effective in preventing primary varicella.

The incubation period is prolonged by 7 days when VZIG is administered, therefore the isolation period extends from day 10 to day 28 after exposure. No data are available on the possible role of acyclovir in the prevention of varicella after exposure.

Recommendation

Immune-compromised children who have been exposed to varicella and have documented negative titers should receive VZIG 1 vial/10 kg IM (maximum dose 5 vials) within 96 hours of exposure. Children who have been vaccinated and/or have positive titers do not need to receive VZIG with exposures.

E. Tuberculosis

Children who are exposed to a potentially infectious case of tuberculosis should undergo tuberculin skin testing (purified protein derivative, with appropriate controls) and a chest roentgenogram. However, they may be anergic, and negative skin test results do not indicate lack of disease.

Recommendation

Administer prophylactic isoniazid (10 mg/kg/day by mouth; maximum dose 300 mg/day) for 12 months to immune-compromised patients with a significant exposure to tuberculosis, irrespective of skin test results.

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Cancer

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