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Guidelines for Vaccination of Solid Organ Transplant Candidates and Recipients

2009; Elsevier BV; Volume: 9; Linguagem: Inglês

10.1111/j.1600-6143.2009.02917.x

1600-6143

L. Danzinger-Isakov, Deepali Kumar,

SARS-CoV-2 and COVID-19 Research

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) (1Avery RK Michaels M Update on immunizations in solid organ transplant recipients: What clinicians need to know.Am J Transplant. 2008; 8: 9-14Crossref PubMed Scopus (97) Google Scholar). 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).Tabled 1PEDIATRIC VACCINESVaccineInactivated/ live attenuated (I/LA)Recommended 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.Recommended after transplantMonitor vaccine titersQuality of evidenceInfluenza (2Mack DR Chartrand SA Ruby EI Antonson DL Shaw Jr, BW Heffron TG Influenza vaccination following liver transplantation in children.Liver Transpl Surg. 1996; 2: 431-437Crossref PubMed Scopus (44) Google Scholar, 3Madan 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: 712-718Crossref PubMed Scopus (64) Google Scholar, 4Duchini A Hendry RM Nyberg LM Viernes ME Pockros PJ Immune response to influenza vaccine in adult liver transplant recipients.Liver Transpl. 2001; 7: 311-313Crossref PubMed Scopus (78) Google Scholar, 5Scharpe J Evenepoel P Maes B et al.Influenza vaccination is efficacious and safe in renal transplant recipients.Am J Transplant. 2008; 8: 332-337Crossref PubMed Scopus (147) Google Scholar, 6Manuel 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: 2567-2572Crossref PubMed Scopus (57) Google Scholar)IYesYesNoII-1LANoNoNoIIIHepatitis B (7Arslan 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: 314-320Crossref PubMed Scopus (79) Google Scholar, 8Horlander 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: 304-307Crossref PubMed Google Scholar, 9Loinaz C De Juanes JR Gonzalez EM et al.Hepatitis B vaccination results in 140 liver transplant recipients.Hepatogastroenterology. 1997; 44: 235-238PubMed Google Scholar, 10Duca 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: 168-170Crossref PubMed Scopus (36) Google Scholar, 11Carey 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: 1590-1592PubMed Google Scholar, 12Foster WQ Murphy A Vega DJ Smith AL Hott BJ Book WM Hepatitis B vaccination in heart transplant candidates.J Heart Lung Transplant. 2006; 25: 106-109Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 13European Consensus Group on hepatitis B immunity.Lancet. 2000; 355: 561-565Abstract Full Text Full Text PDF PubMed Scopus (441) Google Scholar)IYesYes2Routine 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).Yes2Routine 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).II-1Hepatitis A (14Stark 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: 2014-2017Crossref PubMed Scopus (89) Google Scholar, 15Gunther 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: 477-479Crossref PubMed Scopus (94) Google Scholar)IYesYesYesII-1PertussisIYesYesNoIIIDiphtheria (16Balloni 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: 2507-2511Crossref PubMed Scopus (39) Google Scholar, 17Neu 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: 297-299PubMed Google Scholar, 18Pedrazzi C Ghio L Balloni A et al.Duration of immunity to diphtheria and tetanus in young kidney transplant patients.Pediatr Transplant. 1999; 3: 109-114Crossref PubMed Scopus (32) Google Scholar, 19Enke BU Bokenkamp A Offner G Bartmann P Brodehl J Response to diphtheria and tetanus booster vaccination in pediatric renal transplant recipients.Transplantation. 1997; 64: 237-241Crossref PubMed Scopus (60) Google Scholar)IYesYesNoIITetanus (16Balloni 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: 2507-2511Crossref PubMed Scopus (39) Google Scholar, 17Neu 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: 297-299PubMed Google Scholar, 18Pedrazzi C Ghio L Balloni A et al.Duration of immunity to diphtheria and tetanus in young kidney transplant patients.Pediatr Transplant. 1999; 3: 109-114Crossref PubMed Scopus (32) Google Scholar, 19Enke BU Bokenkamp A Offner G Bartmann P Brodehl J Response to diphtheria and tetanus booster vaccination in pediatric renal transplant recipients.Transplantation. 1997; 64: 237-241Crossref PubMed Scopus (60) Google Scholar)IYesYesYesII-1Inactivated Polio vaccine (16Balloni 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: 2507-2511Crossref PubMed Scopus (39) Google Scholar, 17Neu 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: 297-299PubMed Google Scholar, 18Pedrazzi C Ghio L Balloni A et al.Duration of immunity to diphtheria and tetanus in young kidney transplant patients.Pediatr Transplant. 1999; 3: 109-114Crossref PubMed Scopus (32) Google Scholar, 19Enke BU Bokenkamp A Offner G Bartmann P Brodehl J Response to diphtheria and tetanus booster vaccination in pediatric renal transplant recipients.Transplantation. 1997; 64: 237-241Crossref PubMed Scopus (60) Google Scholar)IYesYesNoII-2H. influenzae (20Sever 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: 55-59Crossref PubMed Scopus (37) Google Scholar)IYesYesYes3Serologic 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.II-1S. pneumoniae 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: (conjugate vaccine) (1Avery RK Michaels M Update on immunizations in solid organ transplant recipients: What clinicians need to know.Am J Transplant. 2008; 8: 9-14Crossref PubMed Scopus (97) Google Scholar, 21Blumberg EA Brozena SC Stutman P et al.Immunogenicity of pneumococcal vaccine in heart transplant recipients.Clin Infect Dis. 2001; 32: 307-310Crossref PubMed Scopus (63) Google Scholar, 22Kumar 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: 1639-1645Crossref PubMed Scopus (109) Google Scholar, 23Kumar 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: 633-638Crossref PubMed Scopus (91) Google Scholar, 24Kumar 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: 885-892Crossref PubMed Scopus (57) Google Scholar, 25Lin 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: 160-167Crossref PubMed Scopus (68) Google Scholar)IYesYesYes3Serologic 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.II-1S. pneumoniae4Children 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: (polysaccharide vaccine) (1Avery RK Michaels M Update on immunizations in solid organ transplant recipients: What clinicians need to know.Am J Transplant. 2008; 8: 9-14Crossref PubMed Scopus (97) Google Scholar, 21Blumberg EA Brozena SC Stutman P et al.Immunogenicity of pneumococcal vaccine in heart transplant recipients.Clin Infect Dis. 2001; 32: 307-310Crossref PubMed Scopus (63) Google Scholar, 22Kumar 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: 1639-1645Crossref PubMed Scopus (109) Google Scholar, 23Kumar 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: 633-638Crossref PubMed Scopus (91) Google Scholar, 24Kumar 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: 885-892Crossref PubMed Scopus (57) Google Scholar, 25Lin 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: 160-167Crossref PubMed Scopus (68) Google Scholar)IYesYesYes3Serologic 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.II-1N. meningitidis 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. (1Avery RK Michaels M Update on immunizations in solid organ transplant recipients: What clinicians need to know.Am J Transplant. 2008; 8: 9-14Crossref PubMed Scopus (97) Google Scholar, 26Report 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: 462-465PubMed Google Scholar) (MCV4)IYesYesNoIIIHuman papillomavirus (HPV)6Recommended for all females aged 9–26 years. Immunogenicity studies in posttransplant patients are not published and are area for further study. (1Avery RK Michaels M Update on immunizations in solid organ transplant recipients: What clinicians need to know.Am J Transplant. 2008; 8: 9-14Crossref PubMed Scopus (97) Google Scholar)IYesYesNoIIIRabies7Not routinely administered. Recommended for exposures or potential exposures due to vocation.IYesYesNoIIIVaricella (live-attenuated)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. (27Olson AD Shope TC Flynn JT Pretransplant varicella vaccination is cost-effective in pediatric renal transplantation.Pediatr Transplant. 2001; 5: 44-50Crossref PubMed Scopus (37) Google Scholar, 28Donati M Zuckerman M Dhawan A et al.Response to varicella immunization in pediatric liver transplant recipients.Transplantation. 2000; 70: 1401-1404Crossref PubMed Scopus (43) Google Scholar, 29Khan S Erlichman J Rand EB Live virus immunization after orthotopic liver transplantation.Pediatr Transplant. 2006; 10: 78-82Crossref PubMed Scopus (102) Google Scholar, 30Weinberg 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: 565-568Crossref PubMed Scopus (117) Google Scholar)LAYesNoYesII-1RotavirusLAYesNoNoIIIMeasles8Although 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. (31Flynn 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: 269-272PubMed Google Scholar, 32Turner A Jeyaratnam D Haworth F et al.Measles-associated encephalopathy in children with renal transplants.Am J Transplant. 2006; 6: 1459-1465Crossref PubMed Scopus (30) Google Scholar, 33Rand EB McCarthy CA Whitington PF Measles vaccination after orthotopic liver transplantation.J Pediatr. 1993; 123: 87-89Abstract Full Text PDF PubMed Scopus (91) Google Scholar, 34Shinjoh 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: 6859-6863Crossref PubMed Scopus (53) Google Scholar)LAYesNoYesII-1Mumps8Although 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. (31Flynn 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: 269-272PubMed Google Scholar, 34Shinjoh 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: 6859-6863Crossref PubMed Scopus (53) Google Scholar)LAYesNoYesII-1Rubella8Although 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. (31Flynn 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: 269-272PubMed Google Scholar, 34Shinjoh 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: 6859-6863Crossref PubMed Scopus (53) Google Scholar)LAYesNoYesII-1BCG9The 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.LAYesNoNoIIISmallpox10Transplant 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. (35Dropulic LK Rubin RH Bartlett JG Smallpox vaccination and the patient with an organ transplant.Clin Infect Dis. 2003; 36: 786-788Crossref PubMed Scopus (14) Google 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 (13European Consensus Group on hepatitis B immunity.Lancet. 2000; 355: 561-565Abstract Full Text Full Text PDF PubMed Scopus (441) Google Scholar).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: Open table in a new tab Tabled 1Previous doseRecommendationsFour doses of PrevnarOne dose of Pneumovax 6–8 weeks following last dose of PrevnarOne dose of Pneumovax 5 years after first dose of PneumovaxThree doses of PrevnarOne dose of PrevnarOne dose of Pneumovax 6–8 weeks following last dose of PrevnarOne dose of Pneumovax 5 years after first dose of Pneumovax< 3 doses of PrevnarTwo doses of Prevnar at least 8 weeks apartOne dose of Pneumovax 6–8 weeks following last dose of PrevnarOne dose of Pneumovax 5 years after first dose of PneumovaxOne dose of PneumovaxTwo doses of Prevnar, 6–8 weeks apartOne dose of Pneumovax 5 years after first dose of PneumovaxNone(see <3 doses of Prevnar)5 All 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.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. Open table in a new tab Tabled 1ADULT VACCINESVaccineInactivated/ live attenuated(i/la)Recommended 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.Recommended after transplantMonitor vaccine titersQuality of evidenceInfluenza11Standard 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). (2Mack DR Chartrand SA Ruby EI Antonson DL Shaw Jr, BW Heffron TG Influenza vaccination following liver transplantation in children.Liver Transpl Surg. 1996; 2: 431-437Crossref PubMed Scopus (44) Google Scholar, 3Madan 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: 712-718Crossref PubMed Scopus (64) Google Scholar, 4Duchini A Hendry RM Nyberg LM Viernes ME Pockros PJ Immune response to influenza vaccine in adult liver transplant recipients.Liver Transpl. 2001; 7: 311-313Crossref PubMed Scopus (78) Google Scholar, 5Scharpe J Evenepoel P Maes B et al.Influenza vaccination is efficacious and safe in renal transplant recipients.Am J Transplant. 2008; 8: 332-337Crossref PubMed Scopus (147) Google Scholar, 6Manuel 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: 2567-2572Crossref PubMed Scopus (57) Google Scholar)IYesYesNoII-2LANoNoNoIIIHepatitis B12Routine 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). (7Arslan 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: 314-320Crossref PubMed Scopus (79) Google Scholar, 8Horlander 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: 304-307Crossref PubMed Google Scholar, 11Carey 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: 1590-1592PubMed Google Scholar, 12Foster WQ Murphy A Vega DJ Smith AL Hott BJ Book WM Hepatitis B vaccination in heart transplant candidates.J Heart Lung Transplant. 2006; 25: 106-109Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 13European Consensus Group on hepatitis B immunity.Lancet. 2000; 355: 561-565Abstract Full Text Full Text PDF PubMed Scopus (441) Google Scholar)IYesYesYesII-2Hepatitis A (14Stark 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: 2014-2017Crossref PubMed Scopus (89) Google Scholar, 15Gunther 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: 477-479Crossref PubMed Scopus (94) Google Scholar)IYesYesYesII-1Tetanus (16Balloni 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: 2507-2511Crossref PubMed Scopus (39) Google Scholar, 17Neu 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: 297-299PubMed Google Scholar, 18Pedrazzi C Ghio L Balloni A et al.Duration of immunity to diphtheria and tetanus in young kidney transplant patients.Pediatr Transplant. 1999; 3: 109-114Crossref PubMed Scopus (32) Google Scholar, 19Enke BU Bokenkamp A Offner G Bartmann P Brodehl J Response to diphtheria and tetanus booster vaccination in pediatric renal transplant recipients.Transplantation. 1997; 64: 237-241Crossref PubMed Scopus (60) Google Scholar)IYesYesNoII-2Pertussis (Tdap)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.IYesYesNoIIIInactivated Polio vaccineIYesYesNoIIIS. pneumoniae (polysaccharide vaccine)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. (19Enke BU Bokenkamp A Offner G Bartmann P Brodehl J Response to diphtheria and tetanus booster vaccination in pediatric renal transplant recipients.Transplantation. 1997; 64: 237-241Crossref PubMed Scopus (60) Google Scholar, 20Sever 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: 55-59Crossref PubMed Scopus (37) Google Scholar, 21Blumberg EA Brozena SC Stutman P et al.Immunogenicity of pneumococcal vaccine in heart transplant recipients.Clin Infect Dis. 2001; 32: 307-310Crossref PubMed Scopus (63) Google Scholar, 22Kumar 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: 1639-1645Crossref PubMed Scopus (109) Google Scholar)IYesYesYesIN. meningitidis 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. (MCV4) (1Avery RK Michaels M Update on immunizations in solid organ transplant recipients: What clinicians need to know.Am J Transplant. 2008; 8: 9-14Crossref PubMed Scopus (97) Google Scholar)IYesYesNoIIIRabies16Not routinely administered. Recommended for exposures or potential exposures due to vocation.IYesYesNoIIIHuman papilloma virus (HPV)6Recommended for all females aged 9–26 years. Immunogenicity studies in posttransplant patients are not published and are area for further study.(1Avery RK Michaels M Update on immunizations in solid organ transplant recipients: What clinicians need to know.Am J Transplant. 2008; 8: 9-14Crossref PubMed Scopus (97) Google Scholar)IYesYesNoIIIVaricella (live-attenuated; Varivax)LAYesNoYesII-2Varicella (live-attenuated; Zostavax)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.(1Avery RK Michaels M Update on immunizations in solid organ transplant recipients: What clinicians need to know.Am J Transplant. 2008; 8: 9-14Crossref PubMed Scopus (97) Google Scholar)LAYesNoNoIIIBCG9The 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.LAYesNoNoIIISmallpox10Transplant 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.(35Dropulic LK Rubin RH Bartlett JG Smallpox vaccination and the patient with an organ transplant.Clin Infect Dis. 2003; 36: 786-788Crossref PubMed Scopus (14) Google Scholar)LANoNoNoIIIAnthraxINoNoNoIII11 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(6Manuel 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: 2567-2572Crossref PubMed Scopus (57) Google Scholar).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 (13European Consensus Group on hepatitis B immunity.Lancet. 2000; 355: 561-565Abstract Full Text Full Text PDF PubMed Scopus (441) Google Scholar).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. Open table in a new tab Tabled 1TRAVEL VACCINESVaccineInactivated/ live attenuated (i/la)Recommended before transplantRecommended after transplantMonitor vaccine titersQuality of evidenceV. cholerae 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.(36Ryan ET Calderwood SB Cholera vaccines.Clin Infect Dis. 2000; 31: 561-565Crossref PubMed Scopus (92) Google Scholar)IYesYesNoIIILAYesNoIIIYellow fever19Yellow 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).(37http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/yellow-fever.aspxGoogle Scholar)LAYesNoNoIIIJapanese encephalitis (38Takahashi 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: 2963-2969Crossref PubMed Scopus (100) Google Scholar, 39Kurane I Takasaki T Immunogenicity and protective efficacy of the current inactivated Japanese encephalitis vaccine against different Japanese encephalitis virus strains.Vaccine. 2000; 18: 33-35Crossref PubMed Scopus (66) Google Scholar)IYesYesNoIIISalmonella typhi (40Engels EA Bennish ML Falagas ME Lau J Typhoid fever vaccines.Vaccine. 2000; 18: 1433-1434Crossref PubMed Scopus (8) Google Scholar) (Typhim Vi, intramuscular)IYesYesNoIIISalmonella typhi (Vivotif, oral)LAYesNoNoIIITraveler’s diarrhea and cholera vaccine (Dukoral)20Oral inactivated vaccine against cholera and Enterotoxigenic E. coli. provides short-term protection. Not available in the United States.(41Jelinek T Kollaritsch H Vaccination with Dukoral® against travelers’ diarrhea (ETEC) and cholera.Expert Rev Vaccines. 2008; 7: 561-567Crossref PubMed Scopus (65) Google Scholar)IYesYesNoIII18 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 (37http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/yellow-fever.aspxGoogle Scholar).20 Oral inactivated vaccine against cholera and Enterotoxigenic E. coli. provides short-term protection. Not available in the United States. Open table in a new tab Tabled 1HEALTH CARE WORKERS AND OTHER CLOSE CONTACTS/HOUSEHOLD MEMBERS of TRANSPLANT CANDIDATES/RECIPIENTSVaccineInactivated/ live attenuated (i/la)Recommended before transplant1Recommended after transplantQuality of evidenceInfluenza (2Mack DR Chartrand SA Ruby EI Antonson DL Shaw Jr, BW Heffron TG Influenza vaccination following liver transplantation in children.Liver Transpl Surg. 1996; 2: 431-437Crossref PubMed Scopus (44) Google Scholar, 3Madan 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: 712-718Crossref PubMed Scopus (64) Google Scholar, 4Duchini A Hendry RM Nyberg LM Viernes ME Pockros PJ Immune response to influenza vaccine in adult liver transplant recipients.Liver Transpl. 2001; 7: 311-313Crossref PubMed Scopus (78) Google Scholar, 5Scharpe J Evenepoel P Maes B et al.Influenza vaccination is efficacious and safe in renal transplant recipients.Am J Transplant. 2008; 8: 332-337Crossref PubMed Scopus (147) Google Scholar, 6Manuel 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: 2567-2572Crossref PubMed Scopus (57) Google Scholar)IYesYesII-2LAYesNoIIIHepatitis 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 (13). (7Arslan 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: 314-320Crossref PubMed Scopus (79) Google Scholar, 8Horlander 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: 304-307Crossref PubMed Google Scholar, 9Loinaz C De Juanes JR Gonzalez EM et al.Hepatitis B vaccination results in 140 liver transplant recipients.Hepatogastroenterology. 1997; 44: 235-238PubMed Google Scholar, 10Duca 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: 168-170Crossref PubMed Scopus (36) Google Scholar, 11Carey 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: 1590-1592PubMed Google Scholar, 12Foster WQ Murphy A Vega DJ Smith AL Hott BJ Book WM Hepatitis B vaccination in heart transplant candidates.J Heart Lung Transplant. 2006; 25: 106-109Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 13European Consensus Group on hepatitis B immunity.Lancet. 2000; 355: 561-565Abstract Full Text Full Text PDF PubMed Scopus (441) Google Scholar)IYesYesII-2Hepatitis A (14Stark 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: 2014-2017Crossref PubMed Scopus (89) Google Scholar, 15Gunther 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: 477-479Crossref PubMed Scopus (94) Google Scholar)IYesYesII-1H. influenzae (20Sever 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: 55-59Crossref PubMed Scopus (37) Google Scholar)IYesYesII-2Pertussis (Tdap)IYesYesII-2Varicella (27Olson AD Shope TC Flynn JT Pretransplant varicella vaccination is cost-effective in pediatric renal transplantation.Pediatr Transplant. 2001; 5: 44-50Crossref PubMed Scopus (37) Google Scholar, 28Donati M Zuckerman M Dhawan A et al.Response to varicella immunization in pediatric liver transplant recipients.Transplantation. 2000; 70: 1401-1404Crossref PubMed Scopus (43) Google Scholar, 29Khan S Erlichman J Rand EB Live virus immunization after orthotopic liver transplantation.Pediatr Transplant. 2006; 10: 78-82Crossref PubMed Scopus (102) Google Scholar, 30Weinberg 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: 565-568Crossref PubMed Scopus (117) Google Scholar)LAYesYesII-2Measles (31Flynn 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: 269-272PubMed Google Scholar, 32Turner A Jeyaratnam D Haworth F et al.Measles-associated encephalopathy in children with renal transplants.Am J Transplant. 2006; 6: 1459-1465Crossref PubMed Scopus (30) Google Scholar, 33Rand EB McCarthy CA Whitington PF Measles vaccination after orthotopic liver transplantation.J Pediatr. 1993; 123: 87-89Abstract Full Text PDF PubMed Scopus (91) Google Scholar, 34Shinjoh 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: 6859-6863Crossref PubMed Scopus (53) Google Scholar)LAYesYesII-2Mumps (31Flynn 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: 269-272PubMed Google Scholar, 33Rand EB McCarthy CA Whitington PF Measles vaccination after orthotopic liver transplantation.J Pediatr. 1993; 123: 87-89Abstract Full Text PDF PubMed Scopus (91) Google Scholar, 34Shinjoh 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: 6859-6863Crossref PubMed Scopus (53) Google Scholar)LAYesYesII-2Rubella (31Flynn 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: 269-272PubMed Google Scholar, 33Rand EB McCarthy CA Whitington PF Measles vaccination after orthotopic liver transplantation.J Pediatr. 1993; 123: 87-89Abstract Full Text PDF PubMed Scopus (91) Google Scholar, 34Shinjoh 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: 6859-6863Crossref PubMed Scopus (53) Google Scholar)LAYesYesII-2 Open table in a new tab The authors have nothing to disclose.