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Immunizations in solid organ transplant candidates and recipients

Author
Patricia L Hibberd, MD, PhD
Section Editor
Michael Boeckh, MD
Deputy Editor
Anna R Thorner, MD

INTRODUCTION

Prevention of infection is of paramount importance to the increasing population of solid organ transplant recipients. Infection in these patients results in excessive morbidity and mortality, and antimicrobial therapy is often less effective than in the immunocompetent host [1]. Although immunization appears to be an obvious way to prevent infection, many immunocompromised patients are unable to mount protective immune responses. Furthermore, immunization with live virus vaccines may result in unchecked proliferation of attenuated vaccine strains and is therefore generally avoided in solid organ transplant recipients.

The rationale for immunizing patients who are awaiting or have undergone solid organ transplantation will be reviewed here. Issues related to immunizations in patients who have had hematopoietic cell transplants, who have undergone chemotherapy for treatment of hematologic malignancies or solid tumors, who have HIV infection, and in healthy adults are discussed separately. (See "Immunizations in hematopoietic cell transplant candidates and recipients" and "Immunizations in patients with cancer" and "Immunizations in HIV-infected patients" and "Approach to immunizations in healthy adults".)

IMMUNOGENICITY

The risk of acquiring infection and the inability to prevent infection by immunization are directly related to the patient's "net state of immunosuppression." The greater the degree of immunosuppression, the less likely the patient is to respond to immunization. The factors contributing to immunosuppression in this setting include the underlying disease (eg, renal or hepatic insufficiency), the presence of allograft rejection, and the immunosuppressive therapy administered after transplantation.

Although certain vaccines provide some benefit to the immunocompromised patient, an adequate vaccine response cannot be assumed. Protection of the immunocompromised patient may require the use of vaccines and/or passive immunization (ie, intravenous immunoglobulin) as well as adjunctive measures, such as antiviral drug prophylaxis during influenza A outbreaks.

GUIDELINES

In 2013, the American Society of Transplantation (AST) updated the guidelines for vaccination of pediatric and adult solid organ transplant candidates and recipients as well as healthcare workers, household contacts, and other close contacts of these patients [2]. Also in 2013, the Infectious Diseases Society of America (IDSA) published guidelines for vaccination of immunocompromised hosts, including solid organ transplant recipients (table 1) [3]. The United States Advisory Committee on Immunization Practices (ACIP) also includes immunocompromised hosts in their recommendations.

                           

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Literature review current through: Nov 2016. | This topic last updated: Tue Jul 28 00:00:00 GMT+00:00 2015.
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References
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  1. Hibberd PL, Rubin RH. Approach to immunization in the immunosuppressed host. Infect Dis Clin North Am 1990; 4:123.
  2. Danziger-Isakov L, Kumar D, AST Infectious Diseases Community of Practice. Vaccination in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:311.
  3. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.
  4. Molrine DC, Hibberd PL. Vaccines for transplant recipients. Infect Dis Clin North Am 2001; 15:273.
  5. Gangappa S, Kokko KE, Carlson LM, et al. Immune responsiveness and protective immunity after transplantation. Transpl Int 2008; 21:293.
  6. Avery RK, Michaels M. Update on immunizations in solid organ transplant recipients: what clinicians need to know. Am J Transplant 2008; 8:9.
  7. Burbach G, Bienzle U, Stark K, et al. Influenza vaccination in liver transplant recipients. Transplantation 1999; 67:753.
  8. Kimball P, Verbeke S, Flattery M, et al. Influenza vaccination does not promote cellular or humoral activation among heart transplant recipients. Transplantation 2000; 69:2449.
  9. Lawal A, Basler C, Branch A, et al. Influenza vaccination in orthotopic liver transplant recipients: absence of post administration ALT elevation. Am J Transplant 2004; 4:1805.
  10. Magnani G, Falchetti E, Pollini G, et al. Safety and efficacy of two types of influenza vaccination in heart transplant recipients: a prospective randomised controlled study. J Heart Lung Transplant 2005; 24:588.
  11. White-Williams C, Brown R, Kirklin J, et al. Improving clinical practice: should we give influenza vaccinations to heart transplant patients? J Heart Lung Transplant 2006; 25:320.
  12. Scharpé J, Evenepoel P, Maes B, et al. Influenza vaccination is efficacious and safe in renal transplant recipients. Am J Transplant 2008; 8:332.
  13. Hurst FP, Lee JJ, Jindal RM, et al. Outcomes associated with influenza vaccination in the first year after kidney transplantation. Clin J Am Soc Nephrol 2011; 6:1192.
  14. Blumberg EA, Fitzpatrick J, Stutman PC, et al. Safety of influenza vaccine in heart transplant recipients. J Heart Lung Transplant 1998; 17:1075.
  15. Girndt M, Pietsch M, Köhler H. Tetanus immunization and its association to hepatitis B vaccination in patients with chronic renal failure. Am J Kidney Dis 1995; 26:454.
  16. Krüger S, Müller-Steinhardt M, Kirchner H, Kreft B. A 5-year follow-up on antibody response after diphtheria and tetanus vaccination in hemodialysis patients. Am J Kidney Dis 2001; 38:1264.
  17. Enke BU, Bökenkamp A, Offner G, et al. Response to diphtheria and tetanus booster vaccination in pediatric renal transplant recipients. Transplantation 1997; 64:237.
  18. Huzly D, Neifer S, Reinke P, et al. Routine immunizations in adult renal transplant recipients. Transplantation 1997; 63:839.
  19. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR Morb Mortal Wkly Rep 2011; 60:13.
  20. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older - Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep 2012; 61:468.
  21. Prevots DR, Burr RK, Sutter RW, et al. Poliomyelitis prevention in the United States. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2000; 49:1.
  22. Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2012; 61:816.
  23. French N, Gordon SB, Mwalukomo T, et al. A trial of a 7-valent pneumococcal conjugate vaccine in HIV-infected adults. N Engl J Med 2010; 362:812.
  24. Advisory Committee on Immunization Practices. Summary Report, February 22-23, 2012. http://www.cdc.gov/vaccines/recs/acip/downloads/min-feb12.pdf (Accessed on June 25, 2012).
  25. Nuorti JP, Whitney CG, Centers for Disease Control and Prevention (CDC). Prevention of pneumococcal disease among infants and children - use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine - recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2010; 59:1.
  26. Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among children aged 6-18 years with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2013; 62:521.
  27. American Academy of Pediatrics. Immunization in immunocompromised children. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS. (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.74.
  28. Kumar D, Welsh B, Siegal D, et al. Immunogenicity of pneumococcal vaccine in renal transplant recipients--three year follow-up of a randomized trial. Am J Transplant 2007; 7:633.
  29. Dengler TJ, Strnad N, Bühring I, et al. Differential immune response to influenza and pneumococcal vaccination in immunosuppressed patients after heart transplantation. Transplantation 1998; 66:1340.
  30. Centers for Disease Control and Prevention (CDC). Licensure of a 13-valent pneumococcal conjugate vaccine (PCV13) and recommendations for use among children - Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep 2010; 59:258.
  31. Kumar D, Rotstein C, Miyata G, et al. Randomized, double-blind, controlled trial of pneumococcal vaccination in renal transplant recipients. J Infect Dis 2003; 187:1639.
  32. 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; 47:885.
  33. 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; 81:55.
  34. Ison MG, Hayden FG. Viral infections in immunocompromised patients: what's new with respiratory viruses? Curr Opin Infect Dis 2002; 15:355.
  35. Vilchez RA, McCurry K, Dauber J, et al. Influenza virus infection in adult solid organ transplant recipients. Am J Transplant 2002; 2:287.
  36. Beyer WE, Versluis DJ, Kramer P, et al. Trivalent influenza vaccine in patients on haemodialysis: impaired seroresponse with differences for A-H3N2 and A-H1N1 vaccine components. Vaccine 1987; 5:43.
  37. Versluis DJ, Beyer WE, Masurel N, et al. Value of booster immunisation with influenza vaccine in patients undergoing haemodialysis. Br Med J (Clin Res Ed) 1987; 294:348.
  38. Sanchez-Fructuoso AI, Prats D, Naranjo P, et al. Influenza virus immunization effectivity in kidney transplant patients subjected to two different triple-drug therapy immunosuppression protocols: mycophenolate versus azathioprine. Transplantation 2000; 69:436.
  39. Fraund S, Wagner D, Pethig K, et al. Influenza vaccination in heart transplant recipients. J Heart Lung Transplant 1999; 18:220.
  40. 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; 46:712.
  41. Egli A, Humar A, Widmer LA, et al. Effect of Immunosuppression on T-Helper 2 and B-Cell Responses to Influenza Vaccination. J Infect Dis 2015; 212:137.
  42. Blumberg EA, Albano C, Pruett T, et al. The immunogenicity of influenza virus vaccine in solid organ transplant recipients. Clin Infect Dis 1996; 22:295.
  43. Candon S, Thervet E, Lebon P, et al. Humoral and cellular immune responses after influenza vaccination in kidney transplant recipients. Am J Transplant 2009; 9:2346.
  44. Katerinis I, Hadaya K, Duquesnoy R, et al. De novo anti-HLA antibody after pandemic H1N1 and seasonal influenza immunization in kidney transplant recipients. Am J Transplant 2011; 11:1727.
  45. Brakemeier S, Schweiger B, Lachmann N, et al. Immune response to an adjuvanted influenza A H1N1 vaccine (Pandemrix(®)) in renal transplant recipients. Nephrol Dial Transplant 2012; 27:423.
  46. Schuurmans MM, Tini GM, Dalar L, et al. Pandemic 2009 H1N1 influenza virus vaccination in lung transplant recipients: coverage, safety and clinical effectiveness in the Zurich cohort. J Heart Lung Transplant 2011; 30:685.
  47. Wedemeyer H, Pethig K, Wagner D, et al. Long-term outcome of chronic hepatitis B in heart transplant recipients. Transplantation 1998; 66:1347.
  48. Pessoa MG, Terrault NA, Ferrell LD, et al. Hepatitis after liver transplantation: the role of the known and unknown viruses. Liver Transpl Surg 1998; 4:461.
  49. Kliem V, Ringe B, Holhorst K, Frei U. Kidney transplantation in hepatitis B surface antigen carriers. Clin Investig 1994; 72:1000.
  50. Chung RT, Feng S, Delmonico FL. Approach to the management of allograft recipients following the detection of hepatitis B virus in the prospective organ donor. Am J Transplant 2001; 1:185.
  51. Idilman R, De MN, Colantoni A, et al. The effect of high dose and short interval HBV vaccination in individuals with chronic hepatitis C. Am J Gastroenterol 2002; 97:435.
  52. Villeneuve E, Vincelette J, Villeneuve JP. Ineffectiveness of hepatitis B vaccination in cirrhotic patients waiting for liver transplantation. Can J Gastroenterol 2000; 14 Suppl B:59B.
  53. Domínguez M, Bárcena R, García M, et al. Vaccination against hepatitis B virus in cirrhotic patients on liver transplant waiting list. Liver Transpl 2000; 6:440.
  54. Kallinowski B, Benz C, Buchholz L, Stremmel W. Accelerated schedule of hepatitis B vaccination in liver transplant candidates. Transplant Proc 1998; 30:797.
  55. Loinaz C, de Juanes JR, Gonzalez EM, et al. Hepatitis B vaccination results in 140 liver transplant recipients. Hepatogastroenterology 1997; 44:235.
  56. Chang SH, Suh KS, Yi NJ, et al. Active immunization against de novo hepatitis B virus infection in pediatric patients after liver transplantation. Hepatology 2003; 37:1329.
  57. Serrano B, Bayas JM, Bruni L, Díez C. Solid organ transplantation and response to vaccination. Vaccine 2007; 25:7331.
  58. Grob PJ, Binswanger U, Zaruba K, et al. Immunogenicity of a hepatitis B subunit vaccine in hemodialysis and in renal transplant recipients. Antiviral Res 1983; 3:43.
  59. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1999; 48:1.
  60. Vento S, Garofano T, Renzini C, et al. Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. N Engl J Med 1998; 338:286.
  61. Willner IR, Uhl MD, Howard SC, et al. Serious hepatitis A: an analysis of patients hospitalized during an urban epidemic in the United States. Ann Intern Med 1998; 128:111.
  62. Keeffe EB, Iwarson S, McMahon BJ, et al. Safety and immunogenicity of hepatitis A vaccine in patients with chronic liver disease. Hepatology 1998; 27:881.
  63. Dumot JA, Barnes DS, Younossi Z, et al. Immunogenicity of hepatitis A vaccine in decompensated liver disease. Am J Gastroenterol 1999; 94:1601.
  64. Arslan M, Wiesner RH, Poterucha JJ, et al. Hepatitis A antibodies in liver transplant recipients: evidence for loss of immunity posttransplantation. Liver Transpl 2000; 6:191.
  65. Cohn AC, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62:1.
  66. Human papillomavirus infection. Am J Transplant 2004; 4 Suppl 10:95.
  67. Chin-Hong PV, Kwak EJ, AST Infectious Diseases Community of Practice. Human papillomavirus in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:189.
  68. Kumar D, Unger ER, Panicker G, et al. Immunogenicity of quadrivalent human papillomavirus vaccine in organ transplant recipients. Am J Transplant 2013; 13:2411.
  69. Kwak EJ, Julian K, AST Infectious Diseases Community of Practice. Human papillomavirus infection in solid organ transplant recipients. Am J Transplant 2009; 9 Suppl 4:S151.
  70. Schulman SL, Deforest A, Kaiser BA, et al. Response to measles-mumps-rubella vaccine in children on dialysis. Pediatr Nephrol 1992; 6:187.
  71. Palumbo P, Hoyt L, Demasio K, et al. Population-based study of measles and measles immunization in human immunodeficiency virus-infected children. Pediatr Infect Dis J 1992; 11:1008.
  72. Ellis D, Gilboa N, Bellinger M, Shapiro R. Renal transplantation in infants and children. In: Renal Transplantation, Shaprio R, Simmons RL, Starzl TE (Eds), Appleton and Lange, Stamford, CT 1997. p.461.
  73. Rand EB, McCarthy CA, Whitington PF. Measles vaccination after orthotopic liver transplantation. J Pediatr 1993; 123:87.
  74. Broyer M, Tete MJ, Guest G, et al. Varicella and zoster in children after kidney transplantation: long-term results of vaccination. Pediatrics 1997; 99:35.
  75. Webb NJ, Fitzpatrick MM, Hughes DA, et al. Immunisation against varicella in end stage and pre-end stage renal failure. Trans-Pennine Paediatric Nephrology Study Group. Arch Dis Child 2000; 82:141.
  76. Furth SL, Hogg RJ, Tarver J, et al. Varicella vaccination in children with chronic renal failure. A report of the Southwest Pediatric Nephrology Study Group. Pediatr Nephrol 2003; 18:33.
  77. Barton M, Wasfy S, Melbourne T, et al. Sustainability of humoral responses to varicella vaccine in pediatric transplant recipients following a pretransplantation immunization strategy. Pediatr Transplant 2009; 13:1007.
  78. Pergam SA, Limaye AP, AST Infectious Diseases Community of Practice. Varicella zoster virus in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:138.
  79. Furth SL, Sullivan EK, Neu AM, et al. Varicella in the first year after renal transplantation: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Pediatr Transplant 1997; 1:37.
  80. Zamora I, Simon JM, Da Silva ME, Piqueras AI. Attenuated varicella virus vaccine in children with renal transplants. Pediatr Nephrol 1994; 8:190.
  81. 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; 6:565.
  82. Khan S, Erlichman J, Rand EB. Live virus immunization after orthotopic liver transplantation. Pediatr Transplant 2006; 10:78.
  83. Kraft JN, Shaw JC. Varicella infection caused by Oka strain vaccine in a heart transplant recipient. Arch Dermatol 2006; 142:943.
  84. Levitsky J, Te HS, Faust TW, Cohen SM. Varicella infection following varicella vaccination in a liver transplant recipient. Am J Transplant 2002; 2:880.
  85. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of VariZIG--United States, 2013. MMWR Morb Mortal Wkly Rep 2013; 62:574.
  86. American Academy of Pediatrics. Varicella-Zoster Infections. In: Red Book 2015; Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS. (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.846.
  87. Boeckh M. Prevention of VZV infection in immunosuppressed patients using antiviral agents. Herpes 2006; 13:60.
  88. Weinstock DM, Boeckh M, Boulad F, et al. Postexposure prophylaxis against varicella-zoster virus infection among recipients of hematopoietic stem cell transplant: unresolved issues. Infect Control Hosp Epidemiol 2004; 25:603.
  89. Lynfield R, Herrin JT, Rubin RH. Varicella in pediatric renal transplant recipients. Pediatrics 1992; 90:216.
  90. Stelzmueller I, Wiesmayr S, Swenson BR, et al. Rotavirus enteritis in solid organ transplant recipients: an underestimated problem? Transpl Infect Dis 2007; 9:281.
  91. Centers for Disease Control and Prevention (CDC). Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices--United States, 2013-2014. MMWR Recomm Rep 2013; 62:1.
  92. Smith CK, McNeal MM, Meyer NR, et al. Rotavirus shedding in premature infants following first immunization. Vaccine 2011; 29:8141.
  93. Anderson EJ. Rotavirus vaccines: viral shedding and risk of transmission. Lancet Infect Dis 2008; 8:642.
  94. Payne DC, Edwards KM, Bowen MD, et al. Sibling transmission of vaccine-derived rotavirus (RotaTeq) associated with rotavirus gastroenteritis. Pediatrics 2010; 125:e438.
  95. McVoy MA. Cytomegalovirus vaccines. Clin Infect Dis 2013; 57 Suppl 4:S196.
  96. Griffiths PD, Stanton A, McCarrell E, et al. Cytomegalovirus glycoprotein-B vaccine with MF59 adjuvant in transplant recipients: a phase 2 randomised placebo-controlled trial. Lancet 2011; 377:1256.