Updated AST IDCOP Guidelines for Vaccination of Organ Transplant Recipients

Based on emerging data on live-attenuated and inactivated vaccines, the American Society of Transplantation Infectious Diseases Community of Practice (AST IDCOP) released updated recommendations for the vaccination of solid organ transplant candidates and recipients. This report was published in Clinical Transplantation.

Recommendations for General Principles

Prior to transplantation, all transplant candidates and their household members should have completed the full complement of recommended vaccinations; vaccination status should be reviewed upon first visit and a vaccine strategy should be developed. Inactivated vaccines should be administered 2 weeks prior to transplantation, while live-attenuated vaccines should be administered at least 4 weeks before organ transplant.

If vaccination was not completed prior to transplantation, recommendations by national immunization advisory committees suggest that inactivated vaccines are safe following solid organ transplantation. Post-transplant, live vaccines are not advised, but inactivated vaccines may be administered 3 to 6 months after transplantation, with the exception of the influenza vaccine, which can be administered 1-month post-transplant.

Healthcare workers, family members, close contacts, and the pets of transplant candidates should be fully immunized. These individuals should receive a yearly influenza vaccine, preferably the inactivated influenza vaccine rather than the live-attenuated influenza vaccine. The measles, mumps, rubella (MMR) and varicella vaccines are strongly recommended in household members and close contacts to prevent exposure of transplant patients to wild type viruses.

Recommendations for Specific Vaccines

Influenza Vaccine

The AST IDCOP strongly recommends influenza vaccination for all transplant candidates and recipients. In the post-transplant setting, a high-dose or booster dosing is preferred over standard dosing. Live-attenuated influenza vaccines are strongly recommended against; if a live vaccine is inadvertently given to a transplant recipient, antiviral therapy should be administered, and the patient may be subsequently revaccinated with the inactivated vaccine.

Healthcare workers and close contacts of transplant recipients should also receive inactivated influenza vaccine; however, if live-attenuated influenza vaccine is the only option, infection prevention precautions should be used.

Hepatitis B Vaccine

Prior to transplantation, the Hepatitis B vaccine series should be administered and may follow an accelerated schedule (at 0, 1, 2 months or at 0, 7, 21 days). Patients with end-stage renal disease may receive a higher dose vaccine (40µg). A higher dose vaccine may also be offered in the post-transplant setting, although response rates may be poor therefore protection titers should be closely monitored. Revaccination may be done in non-responders or in patients with waning immunity to Hepatitis B. Surface antibody titers for the Hepatitis B virus are recommended at approximately 4 weeks post-vaccination, to document protection against infection.

Pneumococcal Vaccine

Both 13-valent protein-conjugated, and 23-valent polysaccharide pneumococcal vaccine formulations (PCV13 and PPSV23) are recommended by the AST IDOCOP for transplant candidates and recipients. In immunocompromised patients who have never received the pneumococcal vaccine, a single dose of PCV13 is recommended first, followed by PPSV23 8 weeks later. A PPSV23 booster is recommended 5 years after the first dose of this series is administered

Meningococcal Vaccination

Routine quadrivalent meningococcal vaccine (ACYW) is recommended for all patients aged 11 to 18 years, and all patients > 2months old who meet the following criteria: members of the military, travelers to high risk areas, college freshmen living on campus, properdin deficient, terminal complement component deficient, or those with function or anatomic asplenia.

In at-risk adult transplant candidates, meningococcal ACYW vaccination can be administered before or after transplantation; however, it should be noted that monitoring serologic response is not often feasible outside the research setting. Meningococcal B vaccination is also suggested for at-risk adults and may be given to adolescents under clinical discretion. Use of meninogococcal B vaccination has not yet been evaluated in transplant recipients.

Human papillomavirus (HPV) Vaccine

At-risk patients meeting age-specific criteria should receive a 3-dose HPV vaccine schedule prior to transplantation; however, if the doses are not completed before transplantation, vaccination doses may resume 3 to 6 months post-transplant. Immunogenicity of HPV vaccine in the post-transplant setting has not been extensively studied therefore data is limited.

MMR Vaccine

MMR vaccination is strongly recommended prior to transplantation as the vaccine contains live-attenuated virus and is generally contraindicated post-transplant. However, the vaccine may be carefully administered in a select patient population (commonly in an outbreak setting) with appropriate education on prevention of infectious illnesses and close follow-up. All children should complete a 2-dose MMR series at least 1 month prior to transplantation. Regardless of serology, a documented history of at least 2 doses of the MMR vaccine is sufficient for immunity. Though the MMR vaccine is most effective when administered after 1 year of age, in pediatric patients requiring a transplant, the vaccine may be administered as early as age 6 months, with the second dose as soon as 4 weeks after the initial vaccine.

Varicella Vaccine

Varicella vaccination is also contraindicated post-transplant, and the AST IDOCP recommends administration of the vaccine prior to transplantation in seronegative persons. In pediatric patients requiring a transplant, the varicella vaccine may be administered as early as 9 months old. Ideally, 2 doses should be administered approximately 3 months apart, but a minimum of 4 weeks is acceptable. Seronegative adults should receive one dose of varicella vaccine with serologic testing postvaccination. Should seroconversion not occur, the vaccination may be repeated, if time permits. In individuals who do not seroconvert, postexposure prophylaxis may be administered in warranted situations after transplantation.

Herpes Zoster Vaccine

The AST IDOCP strongly recommends the herpes zoster vaccination in transplant candidates ≥50 years of age, in which subunit vaccine is preferred over live-attenuated vaccine to avoid delays in transplantation. In the post-transplant setting, patients ≥50 years of age may also receive subunit vaccination. Transplant candidates and recipients under 50 may receive the herpes zoster vaccine, however the long-term effects of this vaccine in younger transplant patients is still unknown.

Both authors declare affiliations with the pharmaceutical industry. Please see original reference for a complete list of authors’ disclosures.

Reference

Danziger-Isakov L, Kumar D. Vaccination of solid organ transplant candidates and recipients: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice [published online April 19, 2019]. Clin Transplant. doi: 10.1111/ctr.13563