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Vaccines: the First Line of Infection Prophylaxis


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Amanda Ingemi, PharmD
Transplant Clinical Specialist
Sentara Norfolk General Hospital
Norfolk, VA, USA
aiingemi@sentara.com




Vaccine administration is one of the most effective ways of preventing diseases, specifically influenza, herpes zoster, pneumococcal disease, and others. This disease prevention is especially important in the transplant patient population. Vaccines are can be of later consideration and it can be difficult to keep up-to-date with recommendations that appear to be constantly in flux, especially since there is a lack international consensus from varying bodies of government. In the United States, the Centers for Disease Control (CDC) provide recommendations for vaccinations used in a variety of patient populations. Additionally, the European Centre for Disease Prevention and Control (ECDC) can serve as a valuable resource for information on timing of various immunizations, with country-specific recommendations (National Immunisation schedules in the EU/EEA countries). Another resource available to providers is the Australian Immunisation Handbook, which was last updated in 2013 and contains section pertinent to solid-organ transplant recipients.

In examining the CDC immunization schedule, it can be difficult to follow and recommendations change regularly (1). For example, one of the newest recommendations is that all immunocompromised patients are eligible for the pneumococcal vaccine PCV13 (Prevnar 13®) in addition to the current pneumococcal vaccine recommendation PPSV23 (Pneumovax ®). The conjugate vaccine, Prevnar 13®, is now recommended due to increased immunogenicity over the polysaccharide vaccine, Pneumovax®, eliciting a greater immune response (2). Per the recommendation, Prevnar 13® should be given 8 weeks prior or 1 year after Pneumovax® (1). Various combinations and timing of these two pneumococcal vaccines are recommended for immunocompromised patients depending on international recommendations.

The herpes zoster vaccine (Zostavax®) is another example of a complex recommendation for transplant patients. In the United States, it is FDA approved for patients aged 50 and older, the CDC recommends Zostavax® only for patients aged 60 and older (1,3). The vaccine should not be given after a transplant because it is a live vaccine. In non-transplant patients, providers should follow the FDA indication and receive Zostavax® if they are between 50 and 60 years-old. This age group can pose a problem with insurance reimbursement due to the CDC age recommendation.

Vaccine schedule complexities can easily lead to confusion on both the part of the patient and the practitioner. In an effort to condense the recommendations into a useable format, below is a checklist for adults prior to or after heart and lung transplantation in the United States. Each country has their unique national recommendations and the checklist can be altered to suit.

Vaccine

Eligibility (Dosing)

[ ] Influenza vaccine

All patients
(1 dose per year)

[ ] Pneumococcal
(Pneumovax®)

All patients
(1 dose plus a second dose if >65 years-old and 5 years since last dose)

[ ] Pneumococcal
(Prevnar 13®)

Any patient
[ ] Post transplant
[ ] Asplenic patients
(1 dose 8 weeks before or 1 year after Pneumovax®)

[ ] Tetanus

All patients
(1 dose of Tdap then Td booster every 10 years)

[ ] Zoster (Zostavax®)/
varicella (Varivax®)

Any pre-transplant patient
[ ] >50 years-old
(1 dose of Zostavax®)
[ ] <50 years-old and no evidence of immunity
(2 doses series of Varivax®)
Not for patients on immunosuppression

[ ] Hepatitis B

Any patient
[ ] <60 years-old with diabetes
[ ] Dialysis-dependent
(3 dose series)

[ ] HPV (Gardasil®)

Any patient
[ ] <27 years-old
(3 dose series)

[ ] Meningococcal

Any patient
[ ] Asplenic
(1 dose every 5 years)

[ ] Haemophilus influenza (Hib)

Any patient
[ ] Asplenic
(1 dose per lifetime)

Please note that these recommendations are for adults with disease states commonly seen with heart/lung transplant candidates and recipients. If the patient is <19 years-old or has other diseases, such as chronic liver disease, other vaccine recommendations apply (1). Also, it is important to verify with your national immunization schedules for eligibility, dosing, and timing especially regarding hepatitis B, herpes zoster, poliomyelitis, and pneumococcal vaccine recommendations.

Ideally, these recommended vaccines should be administered prior to a transplant for several reasons:

  1. Live vaccines, like the shingles vaccine, are not indicated for significantly immunocompromised hosts and should be given before a transplant (3);
  2. Vaccines are generally less immunogenic in the post-transplant population therefore vaccines may be more efficacious if given prior to transplantation (4);
  3. Transplant recipients are more susceptible to diseases than the general population, so they should always strive to obtain vaccines at their earliest convenience (5);

For these reasons, the pre-transplant evaluation may be the best time to evaluate vaccination status for each patient (6). Afterward, vaccination history can be assessed on a yearly basis to maintain the recommended prophylaxis.

Whether to recommend a vaccine before or after transplant can be difficult with a patient who you expect will be transplanted soon. If you suspect a transplant within a month, the zoster and varicella vaccines should not be recommended because they are live vaccines that are not indicated for immunocompromised hosts (1,6). As a last resort, if the vaccine is given prior to transplant, the product varicella zoster immune globulin (Varizig®) can be given for vaccine reversal, though it is not FDA-indicated or studied for this purpose (7). Caution should be taken with other live vaccines, such as the tuberculosis vaccine (BCG) and MMR before and after transplantation.

With all vaccines, it takes at least 3-4 weeks with an intact immune system to fully benefit from vaccination, so it is not efficacious to vaccinate immediately before or after a transplant, especially when using t-cell depleting induction agents like thymoglobulin or alemtuzumab.

In an era where transplant patients are living longer, immunization remains an important aspect of chronic health management that should be assessed. Developing a clear plan with both the pre- and post-transplant patient can help prevent communicable diseases and improve quality of life post-transplant. While navigating the maze of immunization can be difficult, development of an institutional protocol based on national recommendations can help ensure patients get the vaccinations that are needed.

Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. CDC. Recommended adult immunization schedule - United States- 2013. Centers for Disease Control and Prevention Web site. Published January 13, 2010. Updated January 29, 2013. Accessed July 25, 2013.
  2. 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. MMWR. October 2012;61:816-819.
  3. Zostavax [package insert]. Whitehouse Station, NJ: Merck & Co, Inc; April 2013.
  4. Avery RK, Ljungman P. Prophylactic measures in the solid-organ recipient before transplantation. Clin Infect Dis 2001;68:337-48.
  5. Fishman JA, Rubin RH. Infection in organ-transplant recipients. N Engl J Med 1998;338(24):1741-51.
  6. Danziger-Isakov L, Kumar D, and the AST Infectious Diseases Community of Practice. Vaccination in solid organ transplantation. Am J Transplant 2013;13:311-317.
  7. Varizig [package insert]. Winnipeg, Canada: Cangene Corp; December 2012.



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