Safe living strategies for the immunocompromised child

Question 1

What medical conditions and treatments are associated with significant immunocompromised states?

Answer 1

Conditions

• HSCT (within 2 years or still taking immunosuppressive drugs)
• solid-organ transplant
• current or recently treated malignancy
• aplastic anemia
• asplenia (risk of S pneumoniae, N meningitidis, Hib)
• HIV (CD4+ count < 200/mm3 in >/= 5 yrs or CD4+ count < 15% in <5 years)
• SCID

Treatments

• high dose steroids (>2mg/kg or >/=20 mg/day pred in >10 kg) for >/= 2 weeks
• Cancer chemotherapeutics (cyclophosphamide)
• antimetabolite (azathioprine)
• transplant-related immunosuppressive drugs (cyclosporine, tacro, siro, MMF)
• Biologics (etanercept, adalimumab, infliximab, rituximab, alemtuzumab)

Question 2

How to build a protective environment for immunocompromised kids?

Answer 2

• immunization
  
  • immunocompromised individuals - receive all routine immunizations
  • HCP - immunizations should be complete
  • Most important: VZV, MMR, annual flu vaccine
• hygiene (hand hygiene)
  
  • before eating/preparing food
  • after urinating/defecating
  • after touching body fluids/excretions/items in contact with feces (clothing, bedding, toilets)
  • after touching plants/soils
  • after collecting/depositing garbage
  • after being in public place or outside home
  • after touching animals

Question 3

What viral resp infections are associated with greatest risk of illness in immunocompromised kids?

Answer 3

RSV, influenza, adenovirus

Question 4

In immunocompromised kids:

How do you reduce risk of resp infections?

Answer 4

• avoid contact with individuals with respiratory illness
• notify physician at first sign of resp illness during influenza season (testing/prophylaxis with neuraminidase inhibitors)
• inform medical team when influenza is in household
• inimize exposure to crowded environments during influenza season
• avoid primary/secondary exposure to tobacco smoke
• avoid risk of fungal pathogens:
  
  • minimize exposure to construction, excavation, renovation sites (Aspergillus)
  • minimize inhalation of fungal spores from plants/animals (farms, barns, pigeon coops, mulching, turning compost piles, cave exploration)
  • don’t smoke marijuana

Question 5

In immunocompromised kids:

How do you reduce risk of waterborne illnesses?

Answer 5

• don’t drink tap water when “boil water” advisories in effect
• drink bottled or boiled water when travelling in areas with suboptimal sanitation
• don’t drink well water (unless screened and monitored)
• don’t drink water from rivers/streams/lakes/ponds
• No hot tubs (pseudomonas, legionella pneumophilia, mycobacterial infections)
• clean abrasions with water and avoid swimming in contaminated water
  
  • waterborne pathogens can enter skin abrasions or resp tract if aspirated

Question 6

In immunocompromised kids:

How do you reduce risk of foodborne illnesses?

Answer 6

• pasteurize milk, fruit, vegetable juices
• avoid cheese from raw or unpasteurized milk (esp soft and semi-soft like Brie, Camembert, blue-veined)
• avoid raw meat, seafood, eggs
• wash raw vegetables (even if labelled prewashed)
• avoid cross contamination

Question 7

In immunocompromised kids:

How do you reduce risk of animal/pet exposures?

Answer 7

• Precautions:
  
  • wait to have pet when pt is less immune suppressed
  • evaluate pets by veterinarian (before being placed with pt)
  • avoid contact with ill animals (esp lip lesions)
  • avoid cleaning birdcages, bird feeders or litter boxes - if not possible, wear disposable gloves and standard surgical mask
  • avoid contact with cleaning aquariums
• Universal principles
  
  • wash hands after contact
  • avoid stray animals
  • Inspect places with raccoons for stool & regularly clean

Question 8

What animal borne pathogens are asplenic kids at risk of?

Answer 8

Capnocytophaga and Salmonella

Question 9

Can immunocompromised kids go to school?

Answer 9

majority can attend school and child care (except SCID)

Question 10

Specific infection with:

reptile & frogs

Answer 10

salmonella

Question 11

Specific infection with:

chick/duckling

Answer 11

salmonella

Question 12

Specific infection with:

rodent

Answer 12

lymphocycit choriomeningitis virus

Question 13

Specific infection with:

kitten

Answer 13

bartonella

Question 14

Specific infection with:

cats

Answer 14

toxoplasma gondii

Question 15

Specific infection with:

puppies, kittens, chicks

Answer 15

campylobacter

Question 16

Specific infection with:

fish tank

Answer 16

mycobacterium marinum

Question 17

Specific infection with:

raccoons

Answer 17

roundworm

Bayliascaris procyonis

Question 18

How to minimize risk of infections in kids with immunocompromise?

Answer 18

• vaccines
• hand washing
• resp, waterborne, foodborne, animal exposure precautions
• travel with health passport
• prevent insect bites
• safer sex practices

most can go back to school (except SCID)

Question 19

What are the most important vaccines for an immunocompromised pt?

Answer 19

VZV, MMR, annual flu