Immunisations

Why is immunisation important in DMD?

Patients with DMD are at risk of breathing problems due to weakness of the breathing muscles. Timely prevention of serious chest infections by vaccination against pneumococcal pneumonia and influenza is useful. It is known that children with brain and muscle diseases constitute a high risk population for death from influenza illness. Hence, the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC) recommended annual influenza vaccination for all children above 6 months with brain and muscle disorders.

Corticosteroid therapy is the cornerstone of management in DMD. However, it may suppress immunity (the body’s defence mechanism against infections) when given daily for long duration in high doses, thus increasing the vulnerability of acquiring infections and infection-related serious complications. Steroids also alter the body’s response to vaccines, reducing its effectiveness in preventing infections. It is, thus, important to complete the recommended routine immunisations before starting corticosteroid therapy.

Which vaccines can be given in DMD?

Vaccines are generally of two types – live-attenuated (containing live but much weakened virus) and killed/inactivated (containing a killed bacteria or virus or small parts of the bacteria). Live-attenuated vaccines carry a risk of causing the disease if given to an individual with low immunity, while inactivated vaccines carry no such risk. Steroid therapy for DMD is usually initiated by 4 years of age at the earliest. Thus, all routine childhood vaccines, according to the National Immunisation Program Schedule, can be given safely and effectively up to 4 years of age.

• Killed or Inactivated vaccines can be administered as is recommended for healthy persons. The vaccines highly recommended in DMD are 23-valent pneumococcal polysaccharide vaccine and the Influenza vaccine.
• Live-virus vaccines are contraindicated in patients with DMD who are on steroid therapy at a dose equivalent to either 2 mg/kg of body weight or a total of 20 mg/day of prednisone.

Physicians should wait at least 3 months after discontinuation of steroid therapy before administering a live-virus vaccine to patients who have received high-dose, systemic steroids for more than two weeks.

The vaccination schedule must be discussed with the physician prior to initiation of steroid therapy.

Immunisation for patients with DMD

The overall immunisation details for patients with DMD are summarised as below:

Key points

• Immunisations against life threatening illnesses constitute an important part of care for individuals with DMD to improve quality of life and longevity.
• Pneumococcal vaccine and annual Influenza vaccine are highly recommended in all individuals with DMD.
• The family members and close contacts of DMD should be vaccinated against Influenza annually.
• The vaccination schedule should be discussed with the treating physician and immunisation with live-attenuated vaccines should be completed before initiation of steroid therapy.

References

1. Emery, A.E., Population frequencies of inherited neuromuscular diseases--a world survey. Neuromuscul Disord, 1991. 1(1): p. 19-29.
2. Bushby, K., et al., Diagnosis and management of Duchenne muscular dystrophy, part 2: implementation of multidisciplinary care. Lancet Neurol, 2010. 9(2): p. 177-89.
3. Havers F, Fry A, Peacock G et al. Influenza vaccination and treatment in children with neurologic disorders. Ther Adv Vaccines,2014, Vol2 (4)95-105.
4. Harper, S., Fukuda, K., Uyeki, T et al. (2005) Prevention and Control of Influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 54: 1–40
5. www.immunise.health.gov.au
6. Recommendations of the Advisory Committee on Immunization Practices (ACIP): Use of Vaccines and Immune Globulins in Persons with Altered Immunocompetence. MMWR Recomm Rep  1993 Vol42/ No RR-04.