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©2015 American Society of Transplantation

American Society of Transplantation Infectious Disease Guidelines, 3rd Edition

>>Interactive Guide<<Vaccination of SOT Candidates and Recipients SectionDeveloped by:Jennifer Trofe-Clark, PharmD, University of PennsylvaniaNicole Theodoropoulos, MD, Ohio State University Kathleen M. Mullane, PharmD, DO, University of Chicago Medical CenterAST Infectious Disease Community of Practice

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General Principles for Candidates and

Recipients

Candidates: Vaccine

Documentation

Recipients (Post-transplant)

Inactive Vaccines

Live Vaccines

Timing of VaccinesGeneral Principles for Healthcare Workers &

Close Contacts

Vaccine Information by Age

Under 18, Pre or Post

18 and Over, Pre or Post

In-depth Vaccine Info by Type

Measles, Mumps, Rubella

Varicella

Herpes Zoster

Influenza

Human Papilloma Virus

Pneumococcal

Tetanus

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The information in these guidelines should not be used as a substitute for clinical judgment.


General Vaccine Principles for Transplant Candidates and Recipients

Candidates

Recipients

• Transplant candidates and recipients are at increased risk of infections complications from vaccine-preventable diseaseso Every effort should be made to ensure that transplant candidates and recipients

have completed the full complement of recommended vaccinations 1-6

• Since the response to many vaccines is diminished in organ failure, transplant candidates should be immunized early in the course of their disease


Candidates Pre-transplant: Vaccine Documentation

Document vaccine history at pre-transplant clinic visit• Refer patient for appropriate vaccines pre-listing. 1-4,6 • Pre-transplant serology for vaccine-preventable disease can guide

recommendations. 1-4,6

Reference: Table 1, Recommendations for Immunization for Pediatric Patients 1

Reference: Table 2, Recommendations for Immunization of Adult Patients 1

Check for new vaccinations and schedule changes at least yearly. 2

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Recipients Post-transplant

Inactive Vaccines

Live Vaccines

Timing of Vaccines

Choose One


Inactive Vaccines• Generally safe after solid organ transplantation 5

• Where data are lacking specifically for transplant candidates or recipients, recommendations made by national immunization advisory committees for general population should be followed 2

• Check for new vaccinations and schedule changes at least yearly 2



Live Vaccines• Live vaccines are not recommended post transplantation 1-4,6

• Pre-transplant live vaccination is suggested if possible 1,6

• Consult an infectious disease specialist regarding incomplete vaccination, ideally prior to listing 1



Timing of Vaccines• Optimal time to give vaccines after transplantation is not

known 1 o Many centers vaccinate at 3-6 months post-transplant when baseline

immunosuppression levels are attained

• Seroconversion should be documented by serologic assays for vaccines when available and protective titers are known 1

• A minimum of 4 weeks should elapse between vaccine administration and evaluation for seroconversion based on protective titers established in the literature 1



General Vaccine Principles for Healthcare Workers & Close Contacts

(1 of 2)• Every effort should be made to ensure that healthcare workers

and close contacts of transplant candidates and recipients have completed the full complement of recommended vaccinationso Inactivated vaccine options are preferred (if available) for household members 1

o With the exception of small pox and oral polio vaccines, there is little to no risk from family members or close contacts receiving live vaccines 2

o If live-attenuated influenza vaccine (LAIV) is the only option for healthcare workers and close contacts, consider use with infection prevention precautions 7

Continued on next slide…


o Rotavirus vaccines pose a theoretical risk of transmission 8

o Viral antigen has been reported to be detected in stool up to 2 weeks after initial dose, therefore good hand washing practices should be used after diaper changes

o Good hand washing practices should be used after diaper changes

o Reference: Table 3, Immunizations for Healthcare Workers and Other Close Contacts/Household Members of Candidates/Recipients 1

o Check for new vaccinations and schedule changes at least yearly 2

General Vaccine Principles for Healthcare Workers & Close Contacts

(2 of 2)



Vaccine Information by Age

Under 18 Years of Age/Pre- or Post-transplant

18 Years of Age and Older/Pre- or Post-transplant

• Transplant candidates and recipients are at increased risk of infectious complications of vaccine-preventable diseases

• Every effort should be made to ensure that transplant candidates and recipients have completed the full complement of recommended vaccinations 1-6.

• Some differences exist between pediatric and adult vaccination recommendations


Under 18 Years of AgePre- or Post-transplant


• Accelerated vaccination schedules are available and should be considered (especially pre-transplant) or for catch-up vaccination 2,6

• Reference: Table 1, Recommendations for Immunization for Pediatric Patients 1

• For transplant recipients who intend to travel to areas of increased risk for infection, immunization status should be reviewedo Reference: Table 4, Travel Vaccine Recommendations 1 o Reference: AST ID Guidelines Travel Medicine Interactive PowerPoint Guide







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18 Years of Age and OlderPre- or Post-transplant


• Reference: Table 2, Recommendations for Immunization of Adult Patients 1

• For transplant recipients who intend to travel to areas of increased risk for infection, immunization status should be reviewedo Reference: Table 4, Travel Vaccine Recommendations 1 o Reference: AST ID Guidelines Travel Medicine Interactive PowerPoint Guide







Vaccine Information by Vaccine Type

Measles, Mumps, Rubella

Varicella

Herpes Zoster

Influenza

• Transplant candidates and recipients are at increased risk of infectious complications of vaccine-preventable diseases• Check for new vaccinations and schedule changes at least yearly 2


Measles, Mumps, Rubella (MMR) Vaccine1 (1 of 2)

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• MMR vaccine contains live attenuated virus• This vaccine is contraindicated post-transplant • Pre-transplant serology should be checked and patient should

be immunized prior to transplantation if they are seronegative

Table 1: Recommendations for Immunization for Pediatric Patients 1

Table 2: Recommendations for Immunization of Adult Patients 1 Table 3: Immunizations for Healthcare Workers and Other Close Contacts/Household Members of Candidates/Recipients 1













Measles, Mumps, Rubella (MMR) Vaccine1 (2 of 2)


• Two live vaccines (e.g., MMR and Varicella) can be administered on the same day; however, if not done on the same day, the second live vaccine should be administered ≥ 28 days later

• Blood products such as intravenous immune globulin can interfere with response to live vaccines

• Live vaccines can interfere with the tuberculin skin test (TST) response. o The TST can be done on the same day as the live vaccine injection; however, if

not done on the same day, it should be done 4-6 weeks later.















Varicella Vaccine1


• Varicella vaccine is a live attenuated viral vaccine• It is indicated prior to transplant in seronegative persons • VZV serology should be checked prior to transplant and the transplant

candidate immunized• Seronegative patients are candidates for post-exposure prophylaxis if

exposed post-transplant • In addition, two live vaccines (e.g., MMR and Varicella) can be

administered on the same day; however, if not done on the same day, the second live vaccine should be administered ≥ 28 days later

• Live vaccines can interfere with the tuberculin skin test (TST) response. o The TST can be done on the same day as the live vaccine injection; however, if

not done on the same day, it should be done 4-6 weeks later.















Herpes Zoster Vaccine1


• Herpes zoster vaccine is a live attenuated vaccine.• This vaccine should not be given post-transplant. Disseminated

disease may occur due to poor cellular immunity against the virus. • Some centers recommend pre-transplant vaccination; however, no

data exist yet to suggest that this will reduce the risk of VZV reactivation post-transplant.















Influenza Vaccine1


• Several formulations are now available but not all have been studied in SOT.9 Recent studies indicate:– High intradermal has similar immunogenicity to standard-dose intramuscular

vaccine10 – Adjuvant data limited but using AS03 adjuvanted vaccines show minor

increases in human leukocyte antigen (HLA) allo-antibody post-vaccination but no increases in rejection rates.11,12

– Live attenuated influenza vaccines are not recommended post-transplant. 9 – If administered inadvertently to a transplant recipient, antiviral therapy and

subsequent revaccination with an inactivated influenza vaccine can be considered (III).1

– Live attenuated vaccine could be given to persons awaiting transplant; however, at least 2 weeks should elapse before transplant. 1















Human Papillomavirus (HPV) Vaccine1


• Three formulations of HPV vaccine are available: – quadrivalent vaccine/Gardasil® (approved females 9-26 years and males 9-26 years) – an AS04-adjuvanted bivalent vaccine/Cervarix® (approved females 10-26 years)– A 9-valent vaccine/Gardasil 9® (approved females 9-26 years and males 9-26 years)13

• Prophylactic vaccination has limited/no effect on existing HPV-related lesions.

• Post-transplant immunogenicity data is limited. 14 • Pre-transplant administration is suggested for those who meet the

indications. • If all doses are not completed pre-transplant, the additional doses

can be resumed starting 3-6 months post-transplant.















Pneumococcal Vaccine1


• Two main formulations are available: – 23-valent polysaccharide vaccine (PPSV) – 13-valent protein-conjugated vaccine (PCV)

• Transplant candidates or recipients should receive:15

– One dose of PCV followed by dose of PPSV 8 weeks later– If previously received PPSV, then one dose of PCV > 1 year after last PPSV dose

• In adults post-transplant, conjugate vaccines produce a similar immunogenicity profile to polysaccharide vaccines. 16















Tetanus (DTaP, Tdap, Td) Vaccine1


• Multiple formulations are available– Diphtheria-tetanus-acellular pertussis (DTaP) vaccine

• Routinely recommended in children, with a single booster dose of a vaccine containing tetanus toxoid

– Reduced diphtheria toxoid, and acellular pertussis (Tdap)• Recommended for 11- to 12- year-olds• At least one dose in adulthood

– Tetanus toxoid and the reduced diphtheria toxoid (Td)• At 10-year intervals throughout life

• Transplant candidates or recipients should receive– One dose of Tdap prior to transplant– At 10 year intervals Td vaccine throughout life















InformationView the full AST ID Guidelines 3rd Edition online

Technical DifficultiesPlease email [email protected].

Questions about the ContentPlease email [email protected] or. [email protected].

Copyright InformationThe ID Guideline, 3rd Edition were published as a special supplement to the American Journal of Transplantation, the journal of the American Society of Transplantation (AST) and the American Society of Transplant Surgeons (ASTS). The copyright to the full contents of the Guidelines is owned by AST and ASTS. The copyright to this interactive guide is owned by AST. Reproduction of any portion of this guide or the full Guidelines without written permission from AST (and ASTS) is unlawful.

DisclaimerThe content, information, opinions, and viewpoints contained in this educational material are those of the authors or contributors of such materials. While the American Society of Transplantation (AST) and its committees take great care to screen the credentials of the contributors and make every attempt to review the contents, AST MAKES NO WARRANTY, EXPRESSED OR IMPLIED, as to the completeness or accuracy of the content contained in the educational materials or on this website. The reader of these materials uses these materials at his or her own risk, and AST shall not be responsible for any errors, omissions, or inaccuracies in these materials, whether arising through negligence, oversight, or otherwise. Reliance on any information appearing in this material is strictly at your own risk. Read AST’s full educational disclaimer online.

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References1. Danziger-Isakov, L, Kumar D and the AST Infectious Diseases Community of Practice. Vaccination in solid organ transplantation. Am J

of Transplant 2013; 13: 311–17.2. http://www.cdc.gov/vaccines/hcp/acip-recs/index.html (accessed March 18, 2015).3. Konkle-Parker-D. Vaccination of immunocompromised individuals: IDSA clinical practice guidelines . HIV Clin 2014; 26:1-3.4. Avery RK, Michaels M. Update on immunizations in solid organ transplant recipients: what clinicians need to know. Am J Transplant

2008;8:9-14.5. Madan RP, Herod BC. Mounting evidence suggests safety and efficacy of immunizations post-transplantation. Am J Transplant 2012;

12: 2871-2.6. Abuali MM, Arnon R, Posada R. An update on immunizations before and after transplantation in the pediatric solid organ transplant

recipient. Pediatr Transplant 2011;15:770-77. Mallory RM, Yi T, Ambrose CS. Shedding of Ann Arbor strain live attenuated influenza vaccine virus in children 6-59 months of age.

Vaccine 2011;29:4322-7.8. Smith CK, McNeal MM, Meyer NR, Haase S, Dekker CL. Rotavirus shedding in premature infants following first immunization.

Vaccine 2011;29:8141-6.9. Kumar D, Blumberg EA, Danziger-Isakov L, et al. Influenza vaccination in the organ transplant recipient: review and summary

recommendations. Am J Transplant 2011;11:2020-30.10. Frenck RW, Jr., Belshe R, Brady RC, et al. Comparison of the immunogenicity and safety of a split-virion, inactivated, trivalent

influenza vaccine (Fluzone(R)) administered by intradermal and intramuscular route in healthy adults. Vaccine;29:5666-74.11. 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;11:1727-33.12. Brakemeier S, Schweiger B, Lachmann N, et al. Immune response to an adjuvanted influenza A H1N1 vaccine (Pandemrix((R)) in

renal transplant recipients. Nephrol Dial Transplant 2012;27:423-8.13. Kirby T. FDA approves new upgraded Gardasil 9. Lancet Oncology 2015; 16:e56.14. Kumar D, Unger ER, Panicker G, et al. Immunogenicity of Quadrivalent Human Papillomavirus Vaccine in Organ Transplant

Recipients. Am J Transplant 2013; 13: 2411–17.15. Use of 13-valent pneumococcal conjugate vaccine for adults with immunocompromising conditions: recommendations of the

Advisory Committee on Immunization Practices (ACIP). Am J Transplant 2013; 232-5.16. Kumar D, Welsh B, Siegal D, Chen MH, Humar A. Immunogenicity of pneumococcal vaccine in renal transplant recipients--three year

follow-up of a randomized trial. Am J Transplant 2007;7:633-8.


http://www.cdc.gov/vaccines/hcp/acip-recs/index.html

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