Safe living strategies for the immunocompromised child

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This practice point draws on recent, reputable care guidelines for immunocompromised patients with specific health conditions ^[1]-[8]. They come from a range of issuing or sponsoring organizations because no single, all-encompassing guideline covers care for all categories of immunocompromised patients. This document offers general principles of care that apply to several categories of at-risk children and youth and, when possible and appropriate, strategies to prevent or manage infection risks in specific groups or individuals.

MEDICAL CONDITIONS AND TREATMENTS ASSOCIATED WITH SIGNIFICANT IMMUNOCOMPROMISED STATES

While the spectrum of severity of immune deficits varies, children and youth whose medical histories include any of the following factors are considered significantly immunocompromised ^[9]-[10]:

• A hematopoietic stem cell transplant (within 2 years of transplantation or still taking immunosuppressive drugs)
• A solid-organ transplant
• Any current or recently treated malignancy
• Aplastic anemia
• Asplenia, with specific risk being encapsulated organisms such as Streptococcus pneumoniae, Neisseria meningitidis or Haemophilus influenzae type b (Hib)
• HIV infection (specifically with a CD4+ count of <200/mm3 in children 5 years or older or a CD4+ count of <15% in infants and children younger than 5 years)
• Severe combined congenital immunodeficiency disease (SCID)

Children who are taking any of the following medications are also considered immunocompromised ^[10]:

• High-dose corticosteroids (specifically >2 mg/kg of body weight or ≥20 mg per day of prednisone or equivalent in individuals weighing >10 kg), when administered for ≥2 weeks
• Cancer chemotherapeutic agents (e.g., cyclophosphamide)
• Antimetabolites (e.g., azathioprine)
• Transplant-related immunosuppressive drugs (e.g., cyclosporine, tacrolimus, sirolimus, mycophenolate mofetil)
• Biologics (e.g., etanercept, adalimumab, infliximab, rituximab, alemtuzumab).

Children and youth with primary immunodeficiency states not listed above may be at increased risk of acquiring infections in community settings, depending on the nature of their immune deficits. Typically, their immunologists provide advice on the extent to which they are susceptible to infections and whether or not they can receive live vaccines. The following are useful resources for families and clinicians caring for children or youth with immunodeficiencies:

• Immune Deficiency Foundation. IDF Patient and Family Handbook for Primary Immunodeficiency Diseases, 5^th edition: http://primaryimmune.org/patient-family-handbook/
• Immunodeficiency Canada: http://immunodeficiency.ca/primary-immunodeficiency/primary-immunodeficiency-pi/

BUILDING A PROTECTIVE ENVIRONMENT

Immunization

Beyond ensuring that immunocompromised individuals receive all routine immunizations that are not contraindicated by their condition (such as live vaccines), health care providers and caregivers should make sure their own immunizations are complete and up-to-date to establish a protective environment ^[11]. For care providers, and especially for the families of patients, immunizations of particular importance include varicella-zoster virus, measles, mumps and rubella and annual influenza vaccines. Furthermore, health care facilities must have infection prevention and control policies and procedures in place to mitigate the risk of infection transmission to anyone, regardless of immune status.

Hand hygiene

To minimize risk of infection in community settings, proper hand hygiene is essential for all day-to-day activities including, but not limited to ^[5]:

• Before eating or preparing food
• After urinating or defecating
• After touching body fluids or excretions or items that might have had contact with human or animal feces (e.g., clothing, bedding, toilets)
• After touching plants or soil
• After collecting or depositing garbage
• After being in any environment outside the home or visiting a public place
• After touching animals

MINIMIZING THE RISK OF SPECIFIC TYPES OF INFECTIONS

Respiratory tract infections

Respiratory viruses associated with the greatest risk for severe illness are respiratory syncytial virus, influenza virus and adenovirus ^[12]-[14]. All immunocompromised persons and their contacts should exercise proper respiratory etiquette and meticulous hand hygiene. Preventive measures to reduce risk for respiratory infections include the following:

• Avoid contact with individuals known to have a respiratory illness, especially when they are symptomatic.
• Notify the child or youth’s treating physician at the first signs of respiratory illness during influenza season. Some patients require testing and treatment or prophylaxis with neuraminidase inhibitors.
• Inform the child or youth’s medical team when there is influenza illness within the household.
• Minimize exposure to crowded environments, such as shopping malls, during influenza/respiratory virus season.
• Avoid primary or secondary exposure to tobacco smoke.
• Avoid risk of exposure to fungal pathogens by:
  • Minimizing exposures to construction, excavation and renovations sites, where fungal spores (e.g., Aspergillus) can thrive,
  • Minimizing  inhalation of fungal spores from plants and animals (i.e. in farms, barns or pigeon coops, or from mulching, turning compost piles or cave exploration),
  • Not smoking marijuana.

Waterborne illnesses

Organisms that are transmitted in contaminated water include, but are not limited to, Cryptosporidium, Giardia, and some enteric gram-negative bacteria. Cryptosporidium is a waterborne parasite ^[15] passed in the stool of infected persons or animals. It is a common cause of symptomatic waterborne disease in North America and significantly increases risk of prolonged diarrhea in immunocompromised individuals ^[16]. Preventive measures to reduce risk of contracting a waterborne illness include the following ^[17]:

• Not drinking tap water in Canada when ‘boil water’ advisories are in effect.
• Drinking only bottled or boiled water when travelling to regions with suboptimal sanitation.
• Not drinking well water unless the source is properly screened and monitored by health authorities.
• Not drinking water directly from rivers, streams, lakes and ponds.
• Not using hot tubs, which have been associated with infections such as Pseudomonas folliculitis ^[18], Legionella pneumophila infections ^[19], and mycobacterial infections ^[20].
• Cleaning abrasions with water from a safe source and avoid swimming in water that may be contaminated. Waterborne pathogens can enter through skin abrasions, or the respiratory tract if aspirated.

Foodborne illnesses

General principles of safe food sourcing and handling apply universally, but foodborne illnesses can affect immunocompromised individuals more severely affected than the general population ^[21].

• All milk, fruit and vegetable juices should be pasteurized.
• Avoid cheeses produced from raw or unpasteurized milk, especially soft and semi-soft varieties (e.g., Brie, Camembert, and blue-veined cheeses).
• Avoid raw meats, seafood and eggs.
• Lettuce and all other raw vegetables should be washed thoroughly, even when they are labelled as prewashed.
• Avoid cross-contamination when preparing foods. Keep cooked and raw foods separate and use different cutting boards or surfaces for raw and cooked foods ^[22].

Animal or pet exposures

Virtually all pets can transmit zoonoses (animalborne infections) to immunocompromised individuals. However, potential for risk should also be weighed against the many emotional benefits of pet ownership for children and families. Animal-associated pathogens of particular concern to immunocompromised children and youth, because they are more vulnerable and can get very ill, include: Bartonella spp., Bordetella bronchiseptica, Campylobacter spp., Capnocytophaga canimorsus, Chlamydia psittaci, Cryptosporidium spp., Giardia lamblia, Mycobacterium marinum, Pasteurella multocida, Rhodococcus equi, Salmonella spp., Toxoplasma gondii, and zoophilic dermatophytes ^[23][24]. Asplenic individuals are also at specific risk for both Capnocytophaga and Salmonella infections. Precautionary measures to reduce risk of contracting an animalborne infection include the following ^[23][24]:

• Wait to acquire a new pet until a child or youth is less immune suppressed, if practical, and consult about risks with a subspecialist in this area.
• A prospective pet should be thoroughly evaluated by a veterinarian before being placed with an immunocompromised child or youth, and an ill pet should be seen by a veterinarian immediately.
• Consider the type of pet and specific risks for infection:
  • Reptiles (snakes, iguanas, lizards and turtles) and frogs carry high risk for Salmonella, and should be avoided.
  • Chicks and ducklings can also transmit Salmonella infections.
  • Rodents, but especially the common house mouse, can transmit lymphocytic choriomeningitis virus.
  • Young cats can transmit Bartonella henselae infections (cat-scratch disease).
  • Cats can transmit Toxoplasma gondii.
  • Puppies, kittens and chicks can transmit Campylobacter infections.
  • Fish tanks may be associated with waterborne pathogens e.g., Mycobacterium marinum.
• Avoid contact with ill animals, especially when they have mouth lesions.
• Avoid cleaning birdcages, bird feeders or litter boxes, and any contact with animal feces. When this is not possible, wear disposable gloves and a standard surgical mask and be sure to wash hands thoroughly after removing gloves.
• Avoid contact with or cleaning aquariums. When this is not possible, wear disposable gloves and be sure to wash hands after removing gloves.

In addition to the above precautions, some general principles apply universally:

• Wash hands with soap and water after contact with any animal or pet, and especially after visits to a petting zoo or farm.
• Avoid contact with stray animals.
• Raccoons are a source of Bayliascaris procyonis (raccoon roundworm). Places where racoons visit should be inspected for stool and regularly cleaned.

Travel advice

Immunocompromised children and youth should be individually evaluated for destination-specific travel risks, if possible by a travel clinic ^[8][25]. Special attention to protective vaccines, and to hand hygiene in airplanes or areas of public transit, is essential. Immunocompromised individuals should travel with a personalized ‘health passport’ that lists their medications and immunizations, describes their condition, and provides their health provider’s contact information. For an example of how a health passport can be created, see: https://www.sickkids.ca/myhealthpassport/.

For information on the returning child traveller with fever, see this practice point: https://cps.ca/en/documents/position/fever-in-the-returning-child-traveller

Prevent insect bites

Immunocompromised individuals should be protected against arthropod-borne illnesses, such as West Nile virus, and mosquito or tick-borne illnesses that can be acquired while travelling. Precautions include using DEET ^[26], dressing protectively and using mosquito netting where mosquito-borne infections are endemic. For more information on preventing mosquito and tick bites, see this practice point: https://cps.ca/en/documents/position/preventing-mosquito-and-tick-bites.

Safer sexual practices

Safer sexual practices help reduce the risk of sexually transmitted infections, which include but are not limited to cytomegalovirus (CMV), hepatitis B and C, herpes simplex virus (HSV), human immune deficiency virus (HIV), human papillomavirus (HPV), and syphilis. Using latex condoms, immunization with hepatitis B and HPV vaccines, having fewer sexual partners and educating the immunocompromised adolescent are essential preventive strategies.

Returning to school or child care settings

General principles relating to school health and the infection control in community settings apply ^[7], with the immunocompromised child or youth’s physician, family and school working closely together to anticipate, assess and monitor risks. With the exception of infants and children with SCID (who have yet to receive a transplant), the vast majority of immunocompromised children and youth can attend school and child care. However, it is prudent to counsel families about contacting their physician immediately when exposures have occurred (e.g., chickenpox in the class). An individualized health plan from the child’s immunologist may be needed in some cases.

Acknowledgements

This practice point has been reviewed by the Acute Care, Adolescent Health and Community Paediatrics Committees of the Canadian Paediatric Society.

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CANADIAN PAEDIATRIC SOCIETY INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE

Members: Michelle Barton-Forbes MD; Sean Bitnun MD; Natalie A Bridger MD (past member); Shalini Desai MD (past member); Michael Forrester MD; Ruth Grimes MD (Board Representative); Nicole Le Saux MD (Chair); Karina Top MD
Liaisons: Upton D Allen MBBS, Canadian Pediatric and Perinatal HIV/AIDS Research Group; Tobey Audcent MD, Committee to Advise on Tropical Medicine and Travel (CATMAT), Public Health Agency of Canada; Carrie Byington MD, Committee on Infectious Diseases, American Academy of Pediatrics; Marc Lebel MD, IMPACT (Immunization Monitoring Program, ACTIVE); Jane McDonald MD, Association of Medical Microbiology and Infectious Disease Canada; Dorothy L. Moore MD, National Advisory Committee on Immunization (NACI); Howard Njoo MD, Public Health Agency of Canada
Consultant: Noni E MacDonald MD
Principal author: Natalie A. Bridger MD, Upton D. Allen MBBS

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.