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Keywords:

  • Adult;
  • pediatric;
  • transplant;
  • travel;
  • vaccine

Transplant candidates and recipients are at increased risk of infectious complications. Every effort should be made to ensure that transplant candidates, their household members and healthcare workers have completed the full complement of recommended vaccinations prior to transplantation. Since the response to many vaccines is diminished in organ failure, transplant candidates should be immunized early in the course of their disease.

It is recommended that vaccination status be reviewed at the time of the first transplant clinic visit, that a vaccine strategy be developed at that time and that the vaccination status be reviewed once again at the time the patient is listed for transplantation.

While every effort should be made to vaccinate prior to transplantation, inactivated vaccines are generally safe after solid organ transplantation. For inactivated vaccines where there are no data for transplant candidates or recipients, recommendations made by ACIP (Advisory Committee on Immunization Practices) for the general population should be followed. There is no evidence to link rejection episodes to vaccination (II-2) (1).

In general, live vaccines are not administered after transplantation; therefore, it is recommended to administer live vaccines such as measles, mumps, rubella (MMR) and Varicella vaccine prior to transplantation. While MMR is the most effective after a year of age when maternal antibody has waned, it can be administered as early as 6 months of age for pediatric patients who may require transplantation. If transplantation has still not occurred by the time the baby is a year of age, the dose should be repeated. The second dose of MMR can be administered as soon as 4 weeks later. A minimum of 4 weeks between live-virus vaccine administration and transplantation is suggested (III).

For patients who are incompletely vaccinated or unvaccinated prior to transplant, consultation with an infectious diseases specialist is recommended. While data regarding timing of vaccines after transplantation have not been fully evaluated, most centers restart vaccination at approximately 3–6 months after transplantation, when baseline immunosuppression levels are attained. The ability to mount an immune response will be impacted by the type and amount of immunosuppression after organ transplantation. Accordingly, seroefficacy should be documented by serologic assays where available. A minimum of 4 weeks should elapse between vaccine administration and evaluation for seroconversion based on protective titers established in the literature. However, given that serology may not be an accurate measure of immunity in the posttransplant period, assays for cellular immunity need further study in this population (III).

Healthcare workers, close contacts and family members should be immunized fully, and, in particular, should receive influenza vaccine yearly. In general, if nonlive vaccine options are available for household members they are preferred. However, with the exception of smallpox and oral-polio vaccines there is little to no risk from the family members or close contacts receiving live vaccines. In fact, it is preferred that household and close contacts be vaccinated against MMR and varicella to prevent the transplanted patient from having contact with wild-type viruses (III).

PEDIATRIC VACCINES

VaccineInactivated/ live attenuated (I/LA)Recommended before transplant1Recommended after transplantMonitor vaccine titersQuality of evidence
  1. 1Whenever possible, the complete complement of vaccines should be administered before transplantation. Vaccines noted to be safe for administration after transplantation may not be sufficiently immunogenic after transplantation.

  2. 2Routine vaccine schedule recommended prior to transplant and as early in the course of disease as possible; vaccine poorly immunogenic after transplantation, and accelerated schedules may be less immunogenic. Serial hepatitis B surface antibody titers should be assessed both before and every 6–12 months after transplantation to assess ongoing immunity (13).

  3. 3Serologic assessment recommended if available. Haemophilus influenzae type B titer greater than 0.15 mg/L is considered protective in the general population. However, the absolute protective titer for Pneumococcus is unknown and may vary by serotype.

  4. 4Children older than 5 years of age should receive Pneumovax. Children less than 2 years of age should receive Prevnar. Those 2–5 years of age should receive pneumococcal vaccine as follows:

Influenza (2–6)IYesYesNoII-1
LANoNoNoIII
Hepatitis B (7–13)IYesYes2Yes2II-1
Hepatitis A (14,15)IYesYesYesII-1
PertussisIYesYesNoIII
Diphtheria (16–19)IYesYesNoII
Tetanus (16–19)IYesYesYesII-1
Inactivated Polio vaccine (16–19)IYesYesNoII-2
H. influenzae (20)IYesYesYes3II-1
S. pneumoniae4 (conjugate vaccine) (1,21–25)IYesYesYes3II-1
S. pneumoniae4 (polysaccharide vaccine) (1,21–25)IYesYesYes3II-1
N. meningitidis5 (1,26) (MCV4)IYesYesNoIII
Human papillomavirus (HPV)6 (1)IYesYesNoIII
Rabies7IYesYesNoIII
Varicella (live-attenuated)8 (27–30)LAYesNoYesII-1
RotavirusLAYesNoNoIII
Measles8 (31–34)LAYesNoYesII-1
Mumps8 (31,34)LAYesNoYesII-1
Rubella8 (31,34)LAYesNoYesII-1
BCG9LAYesNoNoIII
Smallpox10 (35)LANoNoNoIII
AnthraxINoNoNoIII
Previous doseRecommendations
  1. 5All patients aged 11–18 years in the United States and certain patients (members of the military, travelers to high-risk areas, properdindeficient, terminal complement component deficient, those with functional or anatomic asplenia, college freshman living on campus) are candidates for the meningococcal vaccine in the United States and Canada.

  2. 6Recommended for all females aged 9–26 years. Immunogenicity studies in posttransplant patients are not published and are area for further study.

  3. 7Not routinely administered. Recommended for exposures or potential exposures due to vocation.

  4. 8Although not routinely recommended, live-virus vaccines (MMR and Varivax) have been administered to selected organ transplant recipients on minimal immunosuppression. Vaccination is at the discretion of the individual transplant center with the understanding of the potential risks for live-virus vaccination in this population.

  5. 9The indications for Bacillus Calmette-Guerin (BCG) administration in the United States are limited to instances in which exposure to tuberculosis is unavoidable and where measures to prevent its spread have failed or are not possible.

  6. 10Transplant recipients who are face-to-face contacts of a patient with smallpox should be vaccinated; Vaccinia immune globulin may be administered concurrently if available. Those who have less intimate contact should not be vaccinated.

Four doses of PrevnarOne dose of Pneumovax 6–8 weeks following last dose of Prevnar
One dose of Pneumovax 5 years after first dose of Pneumovax
Three doses of PrevnarOne dose of Prevnar
One dose of Pneumovax 6–8 weeks following last dose of Prevnar
One dose of Pneumovax 5 years after first dose of Pneumovax
< 3 doses of PrevnarTwo doses of Prevnar at least 8 weeks apart
One dose of Pneumovax 6–8 weeks following last dose of Prevnar
One dose of Pneumovax 5 years after first dose of Pneumovax
One dose of PneumovaxTwo doses of Prevnar, 6–8 weeks apart
One dose of Pneumovax 5 years after first dose of Pneumovax
None(see <3 doses of Prevnar)

ADULT VACCINES

VaccineInactivated/ live attenuated(i/la)Recommended before transplant1Recommended after transplantMonitor vaccine titersQuality of evidence
  1. 11Standard intramuscular influenza vaccine followed by an intradermal boost did not significantly increase immunogenicity in a cohort of adult lung transplant recipients. Intradermal influenza vaccination is an area for further study in post-transplant patients(6).

  2. 12Routine vaccine schedule recommended prior to transplant and as early as possible in the course of disease; vaccine poorly immunogenic after transplantation and accelerated schedules may be less immunogenic. Serial hepatitis B surface antibody titers should be assessed both before and every 6–12 months after transplantation to assess ongoing immunity (13).

  3. 13If no tetanus booster in the past 10 years, Tdap should be administered. At least one dose of acellular pertussis should be given in adulthood, with particular attention to women of child-bearing age and individuals in contact with infants.

  4. 14Pneumovax should be administered before transplantation and repeated once 3–5 years after initial vaccination. Pneumococcal conjugate vaccine has similar immunogenicity to Pneumovax in adult renal transplant recipients but covers less serotypes (I). Studies indicate declining titers after 3 years with either vaccine (II-1). A prime-boost strategy using seven-valent pneumococcal conjugate vaccine followed by polysaccharide vaccine 8 weeks later had no greater benefit than polysaccharide vaccine alone in adult liver transplant recipients (I); Note that the seven-valent pneumococcal conjugate vaccine is not licensed for use in patients older than 9 years.

  5. 15Recommended for patients who meet the following criteria: members of the military, travelers to high risk areas, properdin deficient, terminal complement component deficient, those with functional or anatomic asplenia, and college freshman living on campus. There are no immunogenicity studies in posttransplant patients.

  6. 16Not routinely administered. Recommended for exposures or potential exposures due to vocation.

  7. 17Vaccine is indicated for persons ≥ 60 years. However, no studies of the herpes zoster vaccine are available in the pretransplant setting. This is an area for further study.

Influenza11 (2–6)IYesYesNoII-2
LANoNoNoIII
Hepatitis B12 (7,8,11–13)IYesYesYesII-2
Hepatitis A (14,15)IYesYesYesII-1
Tetanus (16–19)IYesYesNoII-2
Pertussis (Tdap)13IYesYesNoIII
Inactivated Polio vaccineIYesYesNoIII
S. pneumoniae (polysaccharide vaccine)14 (19–22)IYesYesYesI
N. meningitidis15 (MCV4) (1)IYesYesNoIII
Rabies16IYesYesNoIII
Human papilloma virus (HPV)6(1)IYesYesNoIII
Varicella (live-attenuated; Varivax)LAYesNoYesII-2
Varicella (live-attenuated; Zostavax)17(1)LAYesNoNoIII
BCG9LAYesNoNoIII
Smallpox10(35)LANoNoNoIII
AnthraxINoNoNoIII

TRAVEL VACCINES

VaccineInactivated/ live attenuated (i/la)Recommended before transplantRecommended after transplantMonitor vaccine titersQuality of evidence
  1. 18Inactivated, parenteral cholera vaccine (only approved product available in the United States) is poorly immunogenic and highly reactogenic. Live attenuated vaccine should be avoided in immunosuppressed patients. Oral killed whole cell recombinant B subunit vaccine should pose no risk to immunocompromised patients.

  2. 19Yellow fever vaccination may be required for travel to some countries of Africa and South America, but should be waived if travelers are immunosuppressed. Severely immunosuppressed travelers should be strongly discouraged from traveling to destinations that present true risk of yellow fever (37).

  3. 20Oral inactivated vaccine against cholera and Enterotoxigenic E. coli. provides short-term protection. Not available in the United States.

V. cholerae18(36)IYesYesNoIII
LAYesNo III
Yellow fever19(37)LAYesNoNoIII
Japanese encephalitis (38,39)IYesYesNoIII
Salmonella typhi (40) (Typhim Vi, intramuscular)IYesYesNoIII
Salmonella typhi (Vivotif, oral)LAYesNoNoIII
Traveler's diarrhea and cholera vaccine (Dukoral)20(41)IYesYesNoIII
Table 1.  HEALTH CARE WORKERS AND OTHER CLOSE CONTACTS/HOUSEHOLD MEMBERS of TRANSPLANT CANDIDATES/RECIPIENTS
VaccineInactivated/ live attenuated (i/la)Recommended before transplant1Recommended after transplantQuality of evidence
Influenza (2–6)IYesYesII-2
LAYesNoIII
Hepatitis B2 (7–13)IYesYesII-2
Hepatitis A (14–15)IYesYesII-1
H. influenzae (20)IYesYesII-2
Pertussis (Tdap)IYesYesII-2
Varicella (27–30)LAYesYesII-2
Measles (31–34)LAYesYesII-2
Mumps (31,33,34)LAYesYesII-2
Rubella (31,33,34)LAYesYesII-2

Disclosure

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The authors have nothing to disclose.

References

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