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Vaccination Prior to Organ Transplantation


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Ranny Goldwasser, MD
University Children's Hospital Heidelberg
Heidelberg, Germany
Ranny.goldwasser@med.uni-heidelberg.de



The prevention of systemic viral and bacterial infections through vaccination is one of the basic and most important tasks in the field of pediatrics. In the field of organ transplantation, where the young children are immunosuppressed in order to avoid allograft rejection, avoiding infection through vaccination plays even a more crucial role.

To prevent a graft rejection patients usually need a lifelong immunosuppression medication, which is causing a reduced cell-mediated immunity and a limited antibody production. Besides the increased risk of infections, transplanted patients receive a sometimes life-threatening course of the disease.

The prevention of infections due to vaccination is the least invasive and at the same time the most cost effective approach both to reduce the rate of infection, as well as to reduce the morbidity and mortality rate of the transplanted patients.

Due to the young age of the recipient, the urgent need of a new organ due to cardiac insufficiency, and due to the poor health condition of the pediatric patient, the vaccination status of the patients is mostly prior to transplantation incomplete. Furthermore many patients do not have enough time developing antibodies' titers. Hereto comes, that transplanted patient, as a result of the immunosuppressive therapy, often have inadequate vaccination response or loss of their antibodies' titers. Live attenuated vaccinations are usually contraindicated in this population.

Vaccinations before heart transplantation

If possible before transplanting a patient, physicians should make sure that the vaccination status is fully complete and up to date as using live attenuated vaccination post-transplantation is not recommended and the effect of the passive vaccinations post-transplantation are reduced due to the side effect of the immunosuppressive drugs the patient is receiving [1].

It should also be advised that as the patient's health status is rapidly worsening, one should take into consideration vaccinating the patient in an accelerated schema without waiting for a full vaccination titer.

Basically it is important that prior to transplantation, each patient should be completely vaccinated according to his country own health ministry recommendations. In Germany for example we follow the recommendation of the vaccination commission of the Robert Koch institute [2]. The American society of transplantation (AST) furthermore advice to vaccinate against hepatitis A and influenza [1,3]. In addition, according to the AST, in case of exposition after analysing the risk-benefit usage, a vaccine against rabies or with BCG should be taken into consideration.

The success of vaccination should be, if possible, be done by measuring the antibodies in serum but not earlier than four weeks after the vaccination was given. Transfusions of red blood cells and intravenous immunoglobuline transfusion may cause a false result of the antibody' titer, it is advised to wait 3 months before checking the titer after a transfusion is given to the patient. Other than that, it is recommended, if possible, that after a live attenuated vaccination, a period of four weeks should elapse before transplanting the patient [1,3].

Vaccination from contact persons and pets

Family members of the transplanted patients should have a complete vaccination status and be advised to receive the annually suggested vaccination early in the evaluation. The AST recommends that family members should be vaccinated against measles, mumps and rubella as well as against varicella in order to prevent transplanted patients to be infected by wild type of viruses.

Following a rotavirus vaccination, approx. 50-90% of the vaccinated children can excrete viral antigens in the stool up to two weeks following the vaccination and theoretically transmit the disease to the transplanted patient [4]. Thus the importance of prudent hygiene.

It is also advised that family members and medical personal treating those patients receive annual vaccinations against influenza and hepatitis A and B [1].

The pets of those patients should also have a fully up to date vaccine status including the dangerous zoonoses such as: bordetella, leishmania, leptospira, borrelia, clostridium and rabies virus.

Special vaccination

HPV-Vaccine


Human papilloma viruses (HPV) type 16 or 18 are responsible worldwide for approx. 70% of all cervix carcinoma in women [5]. That's why in Germany it is recommended to vaccinate all girls from ages 9-14 [2]. There are few vaccines available on the market. Till today there remains scant information information concerning the vaccination of transplanted women against HPV.

Meningococcal vaccine

If possible it is advised that the meningococcal tetravalent vaccine (against serotypes ACWY) be given prior to transplantation (1-3). In Germany, this vaccination is approved from the age of one year but in the USA it is already approved for use from the age of three months. The AST recommends for the paediatric transplant to receive the tetravalent meningococcal vaccine.

Pneumococcal vaccine

In order to prevent the infection caused by pneumococcus, there are two different types of vaccines available: one which is a conjugate vaccine to 13 serotypes and the other is a polysaccharide vaccine to 23 serotypes of pneumococcus. The AST recommend that patients younger than two years of age to receive the conjugate vaccine vaccine and those older than 5 years of age to receive the polysaccharide vaccine to the 23 serotypes [1]. Basically following transplantation the pneumococcal vaccine titer should be checked annually. ■

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


References:

  1. Danzinger-Isakov L, Kumar D (2013) Vaccination in solid organ transplantation. Am J Transplant 13 (Suppl4):311-317
  2. Koch-Institut R (2014) Empfehlungen der Ständigen Impfkommission (STIKO) am Robert Koch Institut/Stand: August 2014. Epid Bull 34:305-340
  3. Journal A (2009) KDIGO clinical practice guideline for the case of kidney transplant recipients. Am J Transplant9 (Supp3):S1-S155
  4. Smith CK, McNeal MM, Meyer NR et al (2011) Rotavirus shedding in premature infants following first immunization. Vaccine 29:8141-8146
  5. Chin-HongPV, KwakEJ (2013) Human papillomavirus in solid organ transplantation. Am J Transplant 13 (Suppl4):189-200



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