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Influenza Vaccine Update 2015-2016


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Grant Paulsen, MD
Cincinnati Children's Hospital Medical Center
Cincinnati, OH, USA
Grant.Paulsen@cchmc.org



If you haven't noticed by now, for those of us in the northern hemisphere, influenza season is upon us. It's also generally accepted that influenza infection can be troublesome in heart and lung transplant recipients. And, as they say, an ounce of prevention is worth a pound of cure.

Seasonal influenza activity is reported by the CDC on a weekly basis, available at http://www.cdc.gov/flu/weekly/summary.htm. Based on last year's influenza surveillance, peak activity occurred during the last week of the year, so we are likely far from the end of influenza season and it is not too late to stress the importance of vaccination.

In general, influenza vaccination is recommended for all solid organ transplant (SOT) recipients [1]. If you read no further into this article than this, you just got the most important point. For those that do not need convincing that influenza vaccination is beneficial, a few specifics follow.

Trivalent vaccines contain hemagglutinin (HA) from 2 influenza A strains and 1 influenza B strain. Quadrivalent vaccines contain HA for one additional influenza B strain. Based on the influenza seen last year, the vaccines for 2015-2016 contain HA that is different for two strains [2]: one of the influenza A strains (H3N2) and the influenza B strain. The trivalent vaccine this year contains:

The influenza A (H1N1) component is unchanged and the second influenza B strain in the quadrivalent vaccine is also unchanged (B/Brisbane/60/2008-line (Victoria lineage) [3].

Based on CDC virus characterization through Sept 30, 2015, all influenza A strains were similar to A/California or A/Switzerland, 62% of the flu B were similar to B/Phuket and 38% to B/Brisbane. All of which are components of the 2015-2016 Northern Hemisphere quadrivalent flu vaccine.

However, in the post-transplant population there is more to consider than how good the vaccine match is that year. There are two broad types of flu vaccine: inactivated (IIV) and live attenuated (LAIV). As with all other live attenuated vaccines, LAIV is contraindicated in immunocompromised individuals. Since there is a theoretical risk of transmission following receipt of LAIV, it is also recommended to give the inactivated flu vaccine to people in close contact with SOT patients [1].

The optimal timing of flu vaccination following SOT has not been determined, and practices vary based on local consensus. Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice recommend vaccinating SOT recipients 3-6 months after transplant [4]. In general, while some studies have found significantly decreased responses to vaccination [5], many have reported acceptable response rates to vaccination, and often correlate response with time from transplant. In a series of 51 liver transplant recipients, more than 55% of patient vaccinated 4-12 months after transplant had adequate seroconversion [6]. Another more recent study in 798 adult SOT recipients found similar seroprotection rates in those vaccinated within 6 months compared to those vaccinated more than 6 months after transplant [7], with protection rates of 67% or greater for all vaccine strains in both groups. The same findings were reported when patients vaccinated during the first 3 months following transplant were analyzed as well.

Inactivated flu vaccine is generally well tolerated and regarded as safe in SOT patients. Concerns have been raised regarding possible effects of influenza vaccination on graft dysfunction, either via T cell cross reactivity with allogenic HLA molecules or humoral responses. While two studies have reported increased incidence of anti-HLA antibodies following the 2009 adjuvanted pandemic influenza vaccine [8, 9], neither demonstrated an association with acute rejection. Additionally, multiple other studies have failed to find clinical evidence for allograft dysfunction after influenza vaccination [6, 10-12]. To date, there is no clear evidence that inactivated vaccines contribute to allograft dysfunction, and vaccination remains strongly recommended.

The pediatric SOT group is another population that warrants attention. Children are eligible for the influenza vaccine from 6 months of age and older. Children 6 months through 8 years receiving the flu vaccine for the first time should receive a second dose, 4 weeks after the first dose. If the child has ever received 2 or more total doses, even during non-consecutive flu seasons, then they need only one dose [3]. Children 9 years and older also only need one dose, regardless of prior vaccination. Children less than 3 years old are given the 0.25 mL dose, which is 1/2 of the standard dose.

In summary, based on current information, the strains selected for this year's flu vaccine appear to be well matched to those circulating nationally and while vaccine responses are variable and may be blunted in SOT patients, there is clear benefit to vaccinating this population. ■

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


References:

  1. Kumar, D., et al., Influenza vaccination in the organ transplant recipient: review and summary recommendations. Am J Transplant, 2011. 11(10): p. 2020-30.
  2. Appiah, G.D., et al., Influenza activity - United States, 2014-15 season and composition of the 2015-16 influenza vaccine. MMWR Morb Mortal Wkly Rep, 2015. 64(21): p. 583-90.
  3. Grohskopf, L.A., et al., Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2015-16 Influenza Season. MMWR Morb Mortal Wkly Rep, 2015. 64(30): p. 818-25.
  4. Danziger-Isakov, L., D. Kumar, and A.S.T.I.D.C.o.P. the, Vaccination in Solid Organ Transplantation. American Journal of Transplantation, 2013. 13(s4): p. 311-317.
  5. Duchini, A., et al., Immune response to influenza vaccine in adult liver transplant recipients. Liver Transpl, 2001. 7(4): p. 311-3.
  6. Lawal, A., et al., Influenza vaccination in orthotopic liver transplant recipients: absence of post administration ALT elevation. Am J Transplant, 2004. 4(11): p. 1805-9.
  7. Perez-Romero, P., et al., Influenza vaccination during the first 6 months after solid organ transplantation is efficacious and safe. Clin Microbiol Infect, 2015. 21(11): p. 1040.e11-8.
  8. Katerinis, I., et al., De novo anti-HLA antibody after pandemic H1N1 and seasonal influenza immunization in kidney transplant recipients. Am J Transplant, 2011. 11(8): p. 1727-33.
  9. Brakemeier, S., et al., Immune response to an adjuvanted influenza A H1N1 vaccine (Pandemrix((R))) in renal transplant recipients. Nephrol Dial Transplant, 2012. 27(1): p. 423-8.
  10. Magnani, 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(5): p. 588-92.
  11. Rambal, V., et al., Differential influenza H1N1-specific humoral and cellular response kinetics in kidney transplant patients. Med Microbiol Immunol, 2014. 203(1): p. 35-45.
  12. Vermeiren, P., et al., Influenza vaccination and humoral alloimmunity in solid organ transplant recipients. Transpl Int, 2014. 27(9): p. 903-8.



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