A colleague in North Carolina reports that physicians in his hospital's Neonatal Intensive Care Unit (NICU) have begun to request washed blood products for all NICU patients in order to be able to administer a live rotavirus vaccine to the patient at the time of their discharge. Apparently, this rotavirus vaccine is not recommended if the patient has received a transfusion, unless the blood product is washed. The orders for washed RBCs at his hospital are based on a recent MMWR, (General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices (ACIP); December 1, 2006 / 55(RR15);1-48) TABLE 4, which implies that a patient receiving a blood transfusion should be deferred for several months from receiving live virus vaccines, such as measles, varicella and rotavirus. He asks: "Have any transfusion services received requests for washed blood products for pediatric and neonatal patients receiving live virus vaccines?"

The following comments have been received.

ADDENDA Dec. 19, 2006

1. Dr. Steven Sloan, Medical Director Pediatric Transfusion Medicine at Children's Hospital in Boston (attribution used with permission) reports that his transfusion service has NOT received requests for washed blood components for patients needing to receive vaccines. Furthermore, in Dr. Sloan's opinion, he thinks that it is unnecessary. His interpretation of the CDC/MMWR document is that although it refers to the interval between infusion with an antibody containing product and vaccination, it is intended to apply to concentrated antibody preparations. The main reason for this time interval is that large doses of immunoglobulins, such as the doses frequently administered in intravenous immunoglobulin (IVIG), can blunt the active immune response. However, transfusion with a blood component provides normal levels of immunoglobulins and should not weaken the immune response to vaccines.

Editor's comment: The Table 4 in General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices (ACIP) specifically mentions a time interval of at least 3 months and up to 7 months between infusion of various blood products (RBCs, plasma, platelets) and vaccination with certain vaccines. Is any colleague familiar with published data that support such time intervals, given the opinion expressed above by Dr. Sloan?

ADDENDA Dec. 22, 2006

2. A physician affiliated with a Children's Hospital in Washington has provided information about a posting from Pedpath - Pediatric Pathologists of the World. The posting states that circulating antibody affects the response to rotavirus vaccines, although likely not to the extent that it affects live parentral vaccines [e.g. MMR, varicella] . There are several studies that have shown this, including a recent study by Vesikari et al that examined a neonatal dose of a rhesus rotavirus tetravalent vaccine and found that immune responses were blunted. The authors stated "The frequency of a neutralizing antibody response to RRV and human rotavirus serotypes G1-4 tended to be lower in the group that had received the vaccine at 0-2-4 months compared with those who received it at 2-4-6 months." Some early studies with a rhesus rotavirus vaccine also showed that reactogencitiy was greater among infants vaccinated at an older age, likely because of lack of attenuating effect of maternal antibody. Because [the ACIP Working Group on Rotavirus Vaccine was] ... not as concerned about effect of circulating antibody on rotavirus vaccines as other parentral live vaccines, [they] included in the recommendations that the deferral period following administration of antibody product could be shorter than 42 days if enforcing it would cause the child to become ineligible for vaccination (e.g., >12 weeks at start of series).

ADDENDA Dec. 23, 2006

3. A transfusion medicine physician in Florida reports that he consulted on the discussion question with their Peds ID specialist, at University of FL Jacksonville, who reviewed the post & wrote: "The recommendations are to defer rotavirus vaccine for 6 weeks if possible after blood transfusion (it is actually an antibody containing product). However, the recommendations also say that if this 6 week wait would delay giving the first dose of the rotavirus vaccine after 12 weeks of age, a shorter wait should be considered. The 12 week of age is important because the vaccine is approved for the first dose to be given before the 13th week birthday. This has to do with the concerns about intussusception that were temporally associated with the prior rotavirus vaccine that was taken off the market." Accordingly, his opinion is "we should give the first dose before the 13th week birthday regardless of the time interval between the transfusion, understanding that the vaccine may not be effective. There should be no other adverse consequences if the vaccine is given after less than a 6 week wait."

The Florida transfusion medicine physician adds that they have not had a similar request from their neonatologists, and in conversation, the Peds ID specialist at U of Florida thought some neonatologists may be interpreting the recommendation too aggressively - particularly in view of the labor involved in washing a unit of RBCs, and the impact this would have on designated NICU programs to limit donor exposures in neonates. There is no requirement that the first dose be given before leaving the hospital, so for some NICU alumni, the first dose could be given at a follow-up visit and still be within the 12 week window & the 6 week delay after transfusion. The Peds ID specialist at U of Florida also made the point that the rotavirus vaccine has not been studied in premies, so that no one knows what the efficacy will be.

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Ira A. Shulman, MD
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W. Tait Stevens, MD
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