Guidelines for Vaccination of Solid Organ Transplant Candidates and Recipients

Transcription

1 Wiley Periodicals Inc. C 2009 The Authors Journal compilation C 2009 The American Society of Transplantation and the American Society of Transplant Surgeons doi: /j x Guidelines for Vaccination of Solid Organ Transplant Candidates and Recipients L. Danzinger-Isakov a,,d.kumar b and the AST Infectious Diseases Community of Practice a Center for Pediatric Infectious Diseases, Children s Hospital Cleveland Clinic, Cleveland, OH b Transplant Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada *Corresponding author: Lara Danzinger-Isakov, danzigl@ccf.org Key words: 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). S258

2 Guidelines for Vaccination of Solid Organ Transplant PEDIATRIC VACCINES live before after vaccine Quality of Vaccine attenuated (I/LA) transplant 1 transplant titers evidence Influenza (2 6) I Yes Yes No II-1 LA No No No III Hepatitis B (7 13) I Yes Yes 2 Yes 2 II-1 Hepatitis A (14,15) I Yes Yes Yes II-1 Pertussis I Yes Yes No III Diphtheria (16 19) I Yes Yes No II Tetanus (16 19) I Yes Yes Yes II-1 Inactivated Polio vaccine (16 19) I Yes Yes No II-2 H. influenzae (20) I Yes Yes Yes 3 II-1 S. pneumoniae 4 (conjugate vaccine) (1,21 25) I Yes Yes Yes 3 II-1 S. pneumoniae 4 (polysaccharide vaccine) (1,21 25) I Yes Yes Yes 3 II-1 N. meningitidis 5 (1,26) (MCV4) I Yes Yes No III Human papillomavirus (HPV) 6 (1) I Yes Yes No III Rabies 7 I Yes Yes No III Varicella (live-attenuated) 8 (27 30) LA Yes No Yes II-1 Rotavirus LA Yes No No III Measles 8 (31 34) LA Yes No Yes II-1 Mumps 8 (31,34) LA Yes No Yes II-1 Rubella 8 (31,34) LA Yes No Yes II-1 BCG 9 LA Yes No No III Smallpox 10 (35) LA No No No III Anthrax I No No No III 1 Whenever 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 Routine 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 Serologic 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 Children 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: Previous dose Recommendations Four doses of Prevnar Three doses of Prevnar One dose of Prevnar < 3 doses of Prevnar Two doses of Prevnar at least 8 weeks apart One dose of Pneumovax Two doses of Prevnar, 6 8 weeks apart None (see <3 doses of Prevnar) 5 All patients aged 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. 6 Recommended for all females aged 9 26 years. Immunogenicity studies in posttransplant patients are not published and are area for further study. 7 Not routinely administered. Recommended for exposures or potential exposures due to vocation. 8 Although 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. 9 The 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. 10 Transplant 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. S259

3 Danzinger-Isakov et al. ADULT VACCINES live before after vaccine Quality of Vaccine attenuated(i/la) transplant 1 transplant titers evidence Influenza 11 (2 6) I Yes Yes No II-2 LA No No No III Hepatitis B 12 (7,8,11 13) I Yes Yes Yes II-2 Hepatitis A (14,15) I Yes Yes Yes II-1 Tetanus (16 19) I Yes Yes No II-2 Pertussis (Tdap) 13 I Yes Yes No III Inactivated Polio vaccine I Yes Yes No III S. pneumoniae (polysaccharide vaccine) 14 (19 22) I Yes Yes Yes I N. meningitidis 15 (MCV4) (1) I Yes Yes No III Rabies 16 I Yes Yes No III Human papilloma virus (HPV) 6 (1) I Yes Yes No III Varicella (live-attenuated; Varivax) LA Yes No Yes II-2 Varicella (live-attenuated; Zostavax) 17 (1) LA Yes No No III BCG 9 LA Yes No No III Smallpox 10 (35) LA No No No III Anthrax I No No No III 11 Standard 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). 12 Routine 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). 13 If 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. 14 Pneumovax 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. 15 Recommended 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. 16 Not routinely administered. Recommended for exposures or potential exposures due to vocation. 17 Vaccine 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. TRAVEL VACCINES live attenuated before after vaccine Quality of Vaccine (i/la) transplant transplant titers evidence V. cholerae 18 (36) I Yes Yes No III LA Yes No III Yellow fever 19 (37) LA Yes No No III Japanese encephalitis (38,39) I Yes Yes No III Salmonella typhi (40) (Typhim Vi, intramuscular) I Yes Yes No III Salmonella typhi (Vivotif, oral) LA Yes No No III Traveler s diarrhea and cholera vaccine (Dukoral) 20 (41) I Yes Yes No III 18 Inactivated, 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. 19 Yellow 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). 20 Oral inactivated vaccine against cholera and Enterotoxigenic E. coli. provides short-term protection. Not available in the United States. S260

4 Guidelines for Vaccination of Solid Organ Transplant HEALTH CARE WORKERS AND OTHER CLOSE CONTACTS/HOUSEHOLD MEMBERS of TRANSPLANT CANDIDATES/RECIPIENTS Inactivated/ Recommended Recommended live attenuated before after Quality of Vaccine (i/la) transplant 1 transplant evidence Influenza (2 6) I Yes Yes II-2 LA Yes No III Hepatitis B 2 (7 13) I Yes Yes II-2 Hepatitis A (14 15) I Yes Yes II-1 H. influenzae (20) I Yes Yes II-2 Pertussis (Tdap) I Yes Yes II-2 Varicella (27 30) LA Yes Yes II-2 Measles (31 34) LA Yes Yes II-2 Mumps (31,33,34) LA Yes Yes II-2 Rubella (31,33,34) LA Yes Yes II-2 Disclosure The authors have nothing to disclose. References 1. Avery RK, Michaels M. Update on immunizations in solid organ transplant recipients: What clinicians need to know. Am J Transplant 2008; 8: Mack DR, Chartrand SA, Ruby EI, Antonson DL, Shaw BW Jr, Heffron TG. Influenza vaccination following liver transplantation in children. Liver Transpl Surg 1996; 2: Madan RP, Tan M, Fernandez-Sesma A et al. A prospective, comparative study of the immune response to inactivated influenza vaccine in pediatric liver transplant recipients and their healthy siblings. Clin Infect Dis 2008; 46: Duchini A, Hendry RM, Nyberg LM, Viernes ME, Pockros PJ. Immune response to influenza vaccine in adult liver transplant recipients. Liver Transpl 2001; 7: Scharpe J, Evenepoel P, Maes B et al. Influenza vaccination is efficacious and safe in renal transplant recipients. Am J Transplant 2008; 8: Manuel O, Humar A, Chen MH et al. Immunogenicity and safety of an intradermal boosting strategy for vaccination against influenza in lung transplant recipients. Am J Transplant 2007; 7: Arslan M, Wiesner RH, Sievers C, Egan K, Zein NN. Double-dose accelerated hepatitis B vaccine in patients with end-stage liver disease. Liver Transpl 2001; 7: Horlander JC, Boyle N, Manam R et al. 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J Infect Dis 1999; 180: Gunther M, Stark K, Neuhaus R, Reinke P, Schroder K, Bienzle U. Rapid decline of antibodies after hepatitis A immunization in liver and renal transplant recipients. Transplantation 2001; 71: Balloni A, Assael BM, Ghio L et al. Immunity to poliomyelitis, diphtheria and tetanus in pediatric patients before and after renal or liver transplantation. Vaccine 1999; 17: Neu AM, Warady BA, Furth SL, Lederman HM, Fivush BA. Antibody levels to diphtheria, tetanus, and rubella in infants vaccinated while on PD: A Study of the Pediatric Peritoneal Dialysis Study Consortium. Adv Perit Dial 1997; 13: Pedrazzi C, Ghio L, Balloni A et al. Duration of immunity to diphtheria and tetanus in young kidney transplant patients. Pediatr Transplant 1999; 3: Enke BU, Bokenkamp A, Offner G, Bartmann P, Brodehl J. Response to diphtheria and tetanus booster vaccination in pediatric renal transplant recipients. Transplantation 1997; 64: Sever MS, Yildiz A, Eraksoy H et al. Immune response to Haemophilus influenzae type B vaccination in renal transplant recipients with well-functioning allografts. Nephron 1999; 81: Blumberg EA, Brozena SC, Stutman P et al. Immunogenicity of pneumococcal vaccine in heart transplant recipients. Clin Infect Dis 2001; 32: Kumar D, Rotstein C, Miyata G, Arlen D, Humar A. Randomized, double-blind, controlled trial of pneumococcal vaccination in renal transplant recipients. J Infect Dis. 2003; 187: Kumar D, Welsh B, Siegal D, Chen MH, Humar A. Immunogenicity of pneumococcal vaccine in renal transplant recipients three year follow-up of a randomized trial. Am J Transplant. 2007; 7: Kumar D, Chen MH, Wong G et al. A randomized, double-blind, placebo-controlled trial to evaluate the prime-boost strategy for pneumococcal vaccination in adult liver transplant recipients. Clin Infect Dis 2008; 47: Lin PL, Michaels MG, Green M et al. Safety and immunogenicity of the American Academy of Pediatrics recommended sequential pneumococcal conjugate and polysaccharide vaccine schedule in pediatric solid organ transplant recipients. Pediatrics 2005; 116: Report from the Advisory Committee on Immunization Practices (ACIP): Decision not to recommend routine vaccination of all S261

5 Danzinger-Isakov et al. children aged 2 10 years with quadrivalent meningococcal conjugate vaccine (MCV4). MMWR Morb Mortal Wkly Rep 2008; 57: Olson AD, Shope TC, Flynn JT. Pretransplant varicella vaccination is cost-effective in pediatric renal transplantation. Pediatr Transplant 2001; 5: Donati M, Zuckerman M, Dhawan A et al. Response to varicella immunization in pediatric liver transplant recipients. Transplantation 2000; 70: Khan S, Erlichman J, Rand EB. Live virus immunization after orthotopic liver transplantation. Pediatr Transplant 2006; 10: Weinberg A, Horslen SP, Kaufman SS et al. Safety and immunogenicity of varicella-zoster virus vaccine in pediatric liver and intestine transplant recipients. Am J Transplant 2006; 6: Flynn JT, Frisch K, Kershaw DB, Sedman AB, Bunchman TE. Response to early measles-mumps-rubella vaccination in infants with chronic renal failure and/or receiving peritoneal dialysis. Adv Perit Dial 1999; 15: Turner A, Jeyaratnam D, Haworth F et al. Measles-associated encephalopathy in children with renal transplants. Am J Transplant 2006; 6: Rand EB, McCarthy CA, Whitington PF. Measles vaccination after orthotopic liver transplantation. J Pediatr 1993; 123: Shinjoh M, Miyairi I, Hoshino K, Takahashi T, Nakayama T. Effective and safe immunizations with live-attenuated vaccines for children after living donor liver transplantation. Vaccine 2008; 26: Dropulic LK, Rubin RH, Bartlett JG. Smallpox vaccination and the patient with an organ transplant. Clin Infect Dis 2003; 36: Ryan ET, Calderwood SB. Cholera vaccines. Clin Infect Dis 2000; 31: Takahashi H, Pool V, Tsai TF, Chen RT. Adverse events after Japanese encephalitis vaccination: Review of post-marketing surveillance data from Japan and the United States. The VAERS Working Group. Vaccine 2000; 18: Kurane I, Takasaki T. Immunogenicity and protective efficacy of the current inactivated Japanese encephalitis vaccine against different Japanese encephalitis virus strains. Vaccine 2000; 18(Suppl 2): Engels EA, Bennish ML, Falagas ME, Lau J. Typhoid fever vaccines. Vaccine 2000; 18: Jelinek T, Kollaritsch H. Vaccination with Dukoral R against travelers diarrhea (ETEC) and cholera. Expert Rev Vaccines 2008; 7: S262