In the current era of the COVID-19 pandemic, understanding barriers to vaccinations in immunosuppressed children has become more crucial than ever, according to Cheryl L. Train, MD. “Children with nephrotic syndrome (NS) are at high risk for severe bacterial and viral infections,” says Dr. Tran. “Studies have shown high rates of infection in hospitalized children with NS, which results in high financial burden and significant comorbidities.”

The Advisory Committee on Immunization Practices (ACIP) recommends the pneumococcal polysaccharide vaccine (PPSV23) for pediatric patients with NS. “It’s critical to appreciate the infectious susceptibility associated with NS,” Dr. Tran notes. “Improved vaccination practices could potentially help prevent many of these infections. A critical first step is to understand the practices and patient education on vaccinations provided by physicians and to determine parental knowledge and understanding of vaccine recommendations for their child.”

Vaccine Adherence Influencers

For a study published in Frontiers in Pediatrics, Dr. Tran and colleagues evaluated immunization practices among pediatric nephrologists and assessed the education provided to families of children with NS by pediatric nephrology providers. In addition, parental knowledge of immunization recommendations and predictors of PPSV 23 vaccine adherence were examined. “We wanted to identify factors in both populations that may influence vaccine adherence in children with NS,” Dr. Tran says.

Among providers, 44% self-reported adhering to ACIP guidelines for inactive vaccines and 22% adhered to recommendations for live vaccines. In addition, less than one-third (32%) of parents or guardians reported knowledge that aligned with ACIP guidelines for inactive vaccines and only 1% understood the need for live vaccines. “Vaccine recommendations by providers were a positive predictor of vaccine adherence among pediatric patients with NS,” explains Dr. Tran (Table). “Recommendations by medical providers were paramount in vaccine adherence in this patient population. Importantly, vaccine recommendations may also vary depending on the type of immunosuppression used to manage NS. As such, it’s important for parents and guardians to regularly speak with their child’s pediatric nephrologist about which vaccines can be given to their child at different stages of treatment. These vaccine recommendations should also be communicated to the child’s primary care provider (PCP).”

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Of note, residing in the Midwest was identified as another positive predictor of vaccine adherence, whereas residing in the Coastal region was identified as a negative predictor. This finding may be due to a higher number of participating study sites in the Midwest region compared with other areas surveyed in North America for the study. Providers in the Coastal region were less likely to periodically review immunization records and were more likely to be unsure about recommending the PPSV23 vaccine if their patient had previously received the 7-valent pneumococcal conjugate vaccine (PCV) or PCV-13.

Clarify & Communicate Vaccination Guidance

“Our data show that there were gaps in vaccine knowledge for both pediatric nephrology providers and parents of children with NS who are immunosuppressed,” Dr. Tran says. “The disparate responses among the pediatric nephrology providers and parents or guardians likely reflect individual interpretations of ACIP guidelines. This may partly be due to complex immunosuppression regimens that patients with NS require or result from provider disagreements with vaccination guidelines based on anecdotal experiences with NS relapses and/or beliefs that immunosuppressed patients may not mount a robust vaccine response.”

NS can be a difficult disease to treat, especially in patients who have a steroid-dependent, frequently relapsing, or steroid-resistant disease course. “These patients may have no or very brief periods of time off from immunosuppression medications to keep NS in remission,” explains Dr. Tran. “As a result, opportunities to vaccinate with inactive and/or live vaccines become limited if immunizations are withheld until immune function fully recovers. Withholding vaccinations in this high-risk population may lead to an increased risk of vaccine-preventable disease.”

Dr. Tran recommends all clinicians review the ACIP immunization guidelines annually to be informed of any changes in recommendations for immunizing immunosuppressed patients. “Pediatric nephrologists should ensure that patients with NS have established primary care,” she says. “They also need to be a champion to clarify and communicate vaccination guidance with the patient’s PCP to help improve vaccine adherence. In the future, studies are needed to highlight other areas to improve adherence to vaccines in this patient population.”