Vaccination in Solid Organ Transplantation
2013; Elsevier BV; Volume: 13; Linguagem: Inglês
10.1111/ajt.12122
ISSN1600-6143
AutoresLara Danziger‐Isakov, Deepali Kumar,
Tópico(s)Hepatitis B Virus Studies
ResumoTransplant candidates and recipients are at increased risk of infectious complications of vaccine-preventable diseases. 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 ideally be documented at the pretransplant clinic visit and the patient referred for the appropriate vaccines at the time of listing. Many transplant centers will do routine pretransplant serology for vaccine-preventable diseases such as Hepatitis B, Varicella, measles, mumps and rubella to guide individual vaccine recommendations (Tables 1 and 2).Table 1:Recommendations for immunization of pediatric patientsInactivated/ liveRecommendedRecommendedMonitor vaccineQualityVaccineattentuated (I/LA)before transplant1Whenever 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.after transplanttitersevidenceInfluenza (17Mack DR Chartrand SA Ruby EI Antonson DL Shaw Jr., BW Heffron TG Influenza vaccination following liver transplantation in children.Liver Transpl Surg. 1996; 2: 431-437Google Scholar, 18Madan 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: 712-718Google Scholar, 19Duchini A Hendry RM Nyberg LM Viernes ME Pockros PJ Immune response to influenza vaccine in adult liver transplant recipients.Liver Transpl. 2001; 7: 311-313Google Scholar, 20Scharpe J Evenepoel P Maes B et al.Influenza vaccination is efficacious and safe in renal transplant recipients.Am J Transplant. 2008; 8: 332-337Google Scholar, 21Manuel 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: 2567-2572Google Scholar)IYesYesNoII-1LASee textNoNoIIIHepatitis B2Routine 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 (28).(22Arslan 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: 314-320Google Scholar, 23Horlander JC Boyle N Manam R et al.Vaccination against hepatitis B in patients with chronic liver disease awaiting liver transplantation.Am J Med Sci. 1999; 318: 304-307Google Scholar, 24Loinaz C de Juanes JR Gonzalez EM et al.Hepatitis B vaccination results in 140 liver transplant recipients.Hepatogastroenterology. 1997; 44: 235-238Google Scholar, 25Duca P Del Pont JM D'Agostino D Successful immune response to a recombinant hepatitis B vaccine in children after liver transplantation.J Pediatr Gastroenterol Nutr. 2001; 32: 168-170Google Scholar, 26Carey W Pimentel R Westveer MK Vogt D Broughan T Failure of hepatitis B immunization in liver transplant recipients: results of a prospective trial.Am J Gastroenterol. 1990; 85: 1590-1592Google Scholar, 27Foster WQ Murphy A Vega DJ Smith AL Hott BJ Book WM Hepatitis B vaccination in heart transplant candidates.J Heart Lung Transplant. 2006; 25: 106-109Google Scholar, 28Are booster immunisations needed for lifelong hepatitis B immunity? European Consensus Group on Hepatitis B Immunity.Lancet. 2000; 355: 561-565Google Scholar)IYesYesYesII-1Hepatitis A3For children, routine recommendation for all transplant candidates and recipients. In adults, routinely recommended for liver transplant candidates and recipients. Other adults pre-or posttransplant should receive if high risk of exposure (e.g. travel or residence in high-risk areas, occupational or lifestyle risk of exposure). Monitoring indicated only if ongoing risk for exposure, for example with planned travel to high-risk areas. (29Stark K Gunther M Neuhaus R et al.Immunogenicity and safety of hepatitis A vaccine in liver and renal transplant recipients.J Infect Dis. 1999; 180: 2014-2017Google Scholar,30Gunther 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: 477-479Google Scholar)IYesYesYes (see footnote)II-1PertussisIYesYesNoIIIDiphtheria (31Balloni 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: 2507-2511Google Scholar, 32Neu 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: 297-299Google Scholar, 33Pedrazzi C Ghio L Balloni A et al.Duration of immunity to diphtheria and tetanus in young kidney transplant patients.Pediatr Transplant. 1999; 3: 109-114Google Scholar, 34Enke BU Bokenkamp A Offner G Bartmann P Brodehl J Response to diphtheria and tetanus booster vaccination in pediatric renal transplant recipients.Transplantation. 1997; 64: 237-241Google Scholar)IYesYesNoIITetanus (31Balloni 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: 2507-2511Google Scholar, 32Neu 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: 297-299Google Scholar, 33Pedrazzi C Ghio L Balloni A et al.Duration of immunity to diphtheria and tetanus in young kidney transplant patients.Pediatr Transplant. 1999; 3: 109-114Google Scholar, 34Enke BU Bokenkamp A Offner G Bartmann P Brodehl J Response to diphtheria and tetanus booster vaccination in pediatric renal transplant recipients.Transplantation. 1997; 64: 237-241Google Scholar)IYesYesYesII-1Inactivated Polio vaccine (31Balloni 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: 2507-2511Google Scholar)IYesYesNoII-2H.influenzae4Serologic assessment recommended if available. Haemophilus influenzae type B titer greater than 0.15 mg/L is considered protective in the general population. (35Sever 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: 55-59Google Scholar)IYesYesYesII-1S. pneumoniae5Serologic assessment recommended if available, see text for additional information. (conjugate vaccine) (1Avery RK Michaels M Update on immunizations in solid organ transplant recipients: What clinicians need to know.Am J Transplant. 2008; 8: 9-14Google Scholar,13Kumar 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: 1639-1645Google Scholar, 14Kumar 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: 885-892Google Scholar, 15Kumar 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: 633-638Google Scholar,36Blumberg EA Albano C Pruett T et al.The immunogenicity of influenza virus vaccine in solid organ transplant recipients.Clin Infect Dis. 1996; 22: 295-302Google Scholar,37Lin 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: 160-167Google Scholar)IYesYesYesII-1S. pneumoniae5Serologic assessment recommended if available, see text for additional information. (polysaccharide vaccine) (1Avery RK Michaels M Update on immunizations in solid organ transplant recipients: What clinicians need to know.Am J Transplant. 2008; 8: 9-14Google Scholar,13Kumar 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: 1639-1645Google Scholar, 14Kumar 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: 885-892Google Scholar, 15Kumar 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: 633-638Google Scholar,36Blumberg EA Albano C Pruett T et al.The immunogenicity of influenza virus vaccine in solid organ transplant recipients.Clin Infect Dis. 1996; 22: 295-302Google Scholar,37Lin 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: 160-167Google Scholar)IYesYesYesII-1N. meningitidis6All patients 11–18 years of age, and adults or patients as young as 9 months of age who meet the following criteria: members of the military, travelers to high risk areas, properdin deficient, terminal complement component deficient (including acquired complement deficiency such as prior to starting eculizumab), those with functional or anatomic asplenia, college freshman living on campus. There are no immunogenicity studies in posttransplant patients. For infants and young children, newer vaccination recommendations may become available. Please check local and national recommendations for most up-to-date information. (1Avery RK Michaels M Update on immunizations in solid organ transplant recipients: What clinicians need to know.Am J Transplant. 2008; 8: 9-14Google Scholar,38Report from the Advisory Committee on Immunization Practices (ACIP): Decision not to recommend routine vaccination of all children aged 2–10 years with quadrivalent meningococcal conjugate vaccine (MCV4).MMWR Morb Mortal Wkly Rep. 2008; 57: 462-465Google Scholar)(MCV4)IYesYesNoIIIHuman papillomavirus (HPV)7HPV vaccine, see text.,IYesYesNoIIIRabies8Not routinely administered. Recommended for exposures or potential exposures due to vocation.IYesYesYes (see footnote)IIIVaricella (live-attenuated)9MMR pretransplant, see text. Varicella vaccine should be administered after 12 months of age, and the second vaccine may be given as early as 3 months later. Although not routinely recommended after transplant, live-virus vaccines (MMR and Varivax) have been administered to selected organ transplant recipients on minimal immunosuppression (48). Vaccination is at the discretion of the individual transplant center with the understanding of the potential risks for live-virus vaccination in this population. In adults, there are reports of disseminated vaccine-strain disease occurring with inadvertent varicella vaccination (49); also see text. (39Olson AD Shope TC Flynn JT Pretransplant varicella vaccination is cost-effective in pediatric renal transplantation.Pediatr Transplant. 2001; 5: 44-50Google Scholar, 40Donati M Zuckerman M Dhawan A et al.Response to varicella immunization in pediatric liver transplant recipients.Transplantation. 2000; 70: 1401-1404Google Scholar, 41Khan S Erlichman J Rand EB Live virus immunization after orthotopic liver transplantation.Pediatr Transplant. 2006; 10: 78-82Google Scholar, 42Weinberg 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: 565-568Google Scholar)LAYesNoYesII-1RotavirusLAYesNoNoIIIMeasles9MMR pretransplant, see text. Varicella vaccine should be administered after 12 months of age, and the second vaccine may be given as early as 3 months later. Although not routinely recommended after transplant, live-virus vaccines (MMR and Varivax) have been administered to selected organ transplant recipients on minimal immunosuppression (48). Vaccination is at the discretion of the individual transplant center with the understanding of the potential risks for live-virus vaccination in this population. In adults, there are reports of disseminated vaccine-strain disease occurring with inadvertent varicella vaccination (49); also see text. (43Flynn 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: 269-272Google Scholar, 44Turner A Jeyaratnam D Haworth F et al.Measles-associated encephalopathy in children with renal transplants.Am J Transplant. 2006; 6: 1459-1465Google Scholar, 45Rand EB McCarthy CA Whitington PF Measles vaccination after orthotopic liver transplantation.J Pediatr. 1993; 123: 87-89Google Scholar, 46Shinjoh 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: 6859-6863Google Scholar)LAYesNoYesII-1Mumps9MMR pretransplant, see text. Varicella vaccine should be administered after 12 months of age, and the second vaccine may be given as early as 3 months later. Although not routinely recommended after transplant, live-virus vaccines (MMR and Varivax) have been administered to selected organ transplant recipients on minimal immunosuppression (48). Vaccination is at the discretion of the individual transplant center with the understanding of the potential risks for live-virus vaccination in this population. In adults, there are reports of disseminated vaccine-strain disease occurring with inadvertent varicella vaccination (49); also see text. (43Flynn 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: 269-272Google Scholar,46Shinjoh 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: 6859-6863Google Scholar)LAYesNoYesII-1Rubella9MMR pretransplant, see text. Varicella vaccine should be administered after 12 months of age, and the second vaccine may be given as early as 3 months later. Although not routinely recommended after transplant, live-virus vaccines (MMR and Varivax) have been administered to selected organ transplant recipients on minimal immunosuppression (48). Vaccination is at the discretion of the individual transplant center with the understanding of the potential risks for live-virus vaccination in this population. In adults, there are reports of disseminated vaccine-strain disease occurring with inadvertent varicella vaccination (49); also see text. (32Neu 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: 297-299Google Scholar,43Flynn 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: 269-272Google Scholar,46Shinjoh 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: 6859-6863Google Scholar)LAYesNoYesII-1BCG10The indications for 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.LAYesNoNoIIISmallpox11Transplant 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. (47Dropulic LK Rubin RH Bartlett JG Smallpox vaccination and the patient with an organ transplant.Clin Infect Dis. 2003; 36: 786-788Google Scholar)LANoNoNoIIIAnthraxINoNoNoIII1 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 (28Are booster immunisations needed for lifelong hepatitis B immunity? European Consensus Group on Hepatitis B Immunity.Lancet. 2000; 355: 561-565Google Scholar).3 For children, routine recommendation for all transplant candidates and recipients. In adults, routinely recommended for liver transplant candidates and recipients. Other adults pre-or posttransplant should receive if high risk of exposure (e.g. travel or residence in high-risk areas, occupational or lifestyle risk of exposure). Monitoring indicated only if ongoing risk for exposure, for example with planned travel to high-risk areas.4 Serologic assessment recommended if available. Haemophilus influenzae type B titer greater than 0.15 mg/L is considered protective in the general population.5 Serologic assessment recommended if available, see text for additional information.6 All patients 11–18 years of age, and adults or patients as young as 9 months of age who meet the following criteria: members of the military, travelers to high risk areas, properdin deficient, terminal complement component deficient (including acquired complement deficiency such as prior to starting eculizumab), those with functional or anatomic asplenia, college freshman living on campus. There are no immunogenicity studies in posttransplant patients. For infants and young children, newer vaccination recommendations may become available. Please check local and national recommendations for most up-to-date information.7 HPV vaccine, see text.8 Not routinely administered. Recommended for exposures or potential exposures due to vocation.9 MMR pretransplant, see text. Varicella vaccine should be administered after 12 months of age, and the second vaccine may be given as early as 3 months later. Although not routinely recommended after transplant, live-virus vaccines (MMR and Varivax) have been administered to selected organ transplant recipients on minimal immunosuppression (48Danerseau AM Robinson JL Efficacy and safety of measles, mumps, rubella and varicella live viral vaccines in transplant recipients receiving immunosuppressive drugs.World J Pediatr. 2008; 4: 254-258Google Scholar). Vaccination is at the discretion of the individual transplant center with the understanding of the potential risks for live-virus vaccination in this population. In adults, there are reports of disseminated vaccine-strain disease occurring with inadvertent varicella vaccination (49Kraft JN Shaw JC Varicella infection caused by Oka strain vaccine in a heart transplant recipient.Arch Dermatol. 2006; 142: 943-945Google Scholar); also see text.10 The indications for 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.11 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. Open table in a new tab Table 2:Recommendations for immunization of adult patientsInactivated/ liveRecommendedRecommendedMonitorQualityVaccineattentuated (I/LA)before transplant1Whenever 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.after transplantvaccine titersof evidenceInfluenza2Influenza, see text. (17Mack DR Chartrand SA Ruby EI Antonson DL Shaw Jr., BW Heffron TG Influenza vaccination following liver transplantation in children.Liver Transpl Surg. 1996; 2: 431-437Google Scholar, 18Madan 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: 712-718Google Scholar, 19Duchini A Hendry RM Nyberg LM Viernes ME Pockros PJ Immune response to influenza vaccine in adult liver transplant recipients.Liver Transpl. 2001; 7: 311-313Google Scholar, 20Scharpe J Evenepoel P Maes B et al.Influenza vaccination is efficacious and safe in renal transplant recipients.Am J Transplant. 2008; 8: 332-337Google Scholar, 21Manuel 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: 2567-2572Google Scholar)IYesYesNoII-2LASee textNoNoIIIHepatitis B3Routine 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 (28). (22Arslan 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: 314-320Google Scholar, 23Horlander JC Boyle N Manam R et al.Vaccination against hepatitis B in patients with chronic liver disease awaiting liver transplantation.Am J Med Sci. 1999; 318: 304-307Google Scholar, 24Loinaz C de Juanes JR Gonzalez EM et al.Hepatitis B vaccination results in 140 liver transplant recipients.Hepatogastroenterology. 1997; 44: 235-238Google Scholar, 25Duca P Del Pont JM D'Agostino D Successful immune response to a recombinant hepatitis B vaccine in children after liver transplantation.J Pediatr Gastroenterol Nutr. 2001; 32: 168-170Google Scholar, 26Carey W Pimentel R Westveer MK Vogt D Broughan T Failure of hepatitis B immunization in liver transplant recipients: results of a prospective trial.Am J Gastroenterol. 1990; 85: 1590-1592Google Scholar, 27Foster WQ Murphy A Vega DJ Smith AL Hott BJ Book WM Hepatitis B vaccination in heart transplant candidates.J Heart Lung Transplant. 2006; 25: 106-109Google Scholar, 28Are booster immunisations needed for lifelong hepatitis B immunity? European Consensus Group on Hepatitis B Immunity.Lancet. 2000; 355: 561-565Google Scholar)IYesYesYes (see footnote)II-2Hepatitis A4For children, routine recommendation for all transplant candidates and recipients. In adults, routinely recommended for liver transplant candidates and recipients. Other adults pre-or posttransplant should receive if high risk of exposure (e.g. travel or residence in high-risk areas, occupational or lifestyle risk of exposure). Monitoring indicated only if ongoing risk for exposure, for example with planned travel to high-risk areas. (29Stark K Gunther M Neuhaus R et al.Immunogenicity and safety of hepatitis A vaccine in liver and renal transplant recipients.J Infect Dis. 1999; 180: 2014-2017Google Scholar,30Gunther 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: 477-479Google Scholar)IYesYesYesII-1Tetanus (31Balloni 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: 2507-2511Google Scholar, 32Neu 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: 297-299Google Scholar, 33Pedrazzi C Ghio L Balloni A et al.Duration of immunity to diphtheria and tetanus in young kidney transplant patients.Pediatr Transplant. 1999; 3: 109-114Google Scholar, 34Enke BU Bokenkamp A Offner G Bartmann P Brodehl J Response to diphtheria and tetanus booster vaccination in pediatric renal transplant recipients.Transplantation. 1997; 64: 237-241Google Scholar)IYesYesNoII-2Pertussis (Tdap)5If 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 with in contact with infants.IYesYesNoIIIInactivated Polio vaccineIYesYesNoIIIS. pneumoniae6Serologic assessment recommended if available, see text for additional information. (13Kumar 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: 1639-1645Google Scholar, 14Kumar 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: 885-892Google Scholar, 15Kumar 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: 633-638Google Scholar,36Blumberg EA Albano C Pruett T et al.The immunogenicity of influenza virus vaccine in solid organ transplant recipients.Clin Infect Dis. 1996; 22: 295-302Google Scholar)IYesYesYesIN. meningitidis7All patients 11–18 years of age, and adults or patients as young as 9 months of age who meet the following criteria: members of the military, travelers to high risk areas, properdin deficient, terminal complement component deficient (including acquired complement deficiency such as prior to starting eculizumab), those with functional or anatomic asplenia, college freshman living on campus. There are no immunogenicity studies in posttransplant patients. For infants and young children, newer vaccination recommendations may become available. Please check local and national recommendations for most up-to-date information. (MCV4)IYesYesNoIIIRabies8Not routinely administered. Recommended for exposures or potential exposures due to vocation.IYesYesYes (see footnote)IIIHuman papilloma virus (HPV)9HPV vaccine, see text.IYesYesNoIIIMMR9HPV vaccine, see text.LAYesNoNoII-2Varicella (live-attenuated; Varivax)10MMR pretransplant, see text. Varicella vaccine should be administered after 12 months of age, and the second vaccine may be given as early as 3 months later. Although not routinely recommended after transplant, live-virus vaccines (MMR and Varivax) have been administered to selected organ transplant recipients on minimal immunosuppression (48). Vaccination is at the discretion of the individual transplant center with the understanding of the potential risks for live-virus vaccination in this population. In adults, there are reports of disseminated vaccine-strain disease occurring with inadvertent varicella vaccination (49); also see text.LAYesNoYesII-2Varicella (live-attenuated; Zostavax)11Zoster, see text.LAYesNoNoIIIBCG12The indications for 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.LAYesNoNoIIISmallpox13Transplant 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. (47Dropulic LK Rubin RH Bartlett JG Smallpox vaccination and the patient with an organ transplant.Clin Infect Dis. 2003; 36: 786-788Google Scholar)LANoNoNoIIIAnthraxINoNoNoIII1 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 Influenza, see text.3 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 (28Are booster immunisations needed for lifelong hepatitis B immunity? European Consensus Group on Hepatitis B Immunity.Lancet. 2000; 355: 561-565Google Scholar).4 For children, routine recommendation for all transplant candidates and recipients. In adults
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