Update on Immunizations in Solid Organ Transplant Recipients: What Clinicians Need to Know

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From American Journal of Transplantation

Update on Immunizations in Solid Organ Transplant Recipients: What Clinicians

Need to Know

Posted 03/05/2008

R. K. Avery; M. s

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Abstract and Background

Vaccine-preventable diseases remain a major source of morbidity and mortality in

transplant recipients. Since the publication of the American Society of

Transplantation's guidelines for vaccination of solid organ transplant

recipients in 2004,[1] several new vaccines have been licensed. Transplant

clinicians have been inundated by questions from patients and colleagues

regarding the utility and safety of these vaccines in transplant candidates and

recipients. In addition, new data has appeared regarding utility of some

established vaccines, lack of rejection after vaccination and newer adjuvant

strategies. Literature published between 2004 and 2007 was reviewed in a Medline

search. Guidelines from the Centers for Disease Control and Prevention's

Advisory Committee on Immunization Practices are reviewed and summarized, with

particular attention to vaccines for human papillomavirus, varicella and

varicella-zoster, tetanus-reduced diphtheria-acellular pertussis (Tdap) and

hepatitis B, as well as conjugated meningococcal and conjugated pneumococcal

vaccines. Although randomized controlled trials in transplant recipients have

not been performed for most new licensed vaccines, preliminary recommendations

can be formulated based on current data and guidelines. Further studies will be

important to determine the indications and optimal timing of newer immunizations

and immunization strategies.

Background

In recent years, new licensed vaccines have extended the realm of

vaccine-preventable diseases. As there are already a number of comprehensive

reviews on standard vaccines for transplant candidates and recipients[1-11] and

for potential travelers,[12] the current review will focus on new developments

in this field. Recently licensed vaccines include the human papillomavirus (HPV)

vaccine,[13] the zoster vaccine,[14] the rotavirus vaccine[15] and the

adolescent-adult tetanus-reduced diphtheria-acellular pertussis (Tdap)

vaccine.[16,17] In addition, new strategies for hepatitis B vaccination after

liver transplantation will be discussed.[18-23] The availability of conjugated

meningococcal and pneumococcal vaccines has been a welcome development given

suboptimal immunogenicity of standard vaccines in some studies.[24-29]

Despite the burden of illness due to vaccine-preventable diseases in transplant

recipients, licensed vaccines remain underutilized, as demonstrated in a 1997

national survey of bone marrow transplant centers.[30] Guidelines for

revaccination after hematopoietic stem cell transplantation have been published

by the Centers for Disease Control and Prevention (CDC), the Infectious Diseases

Society of America (IDSA) and the American Society for Blood and Marrow

Transplantation (ASBMT).[31] The American Society of Transplantation's (AST)

Guidelines for the Prevention and Management of Infectious Complications of

Solid Organ Transplantation included tables of recommended vaccinations for

transplant candidates and recipients.[1] However, there continues to be a gap

between guidelines and practice.

One reason for this gap could be concern that immunizations might trigger

allograft rejection,[32] although most large studies in the past have not shown

an increase in rejection rates after standard immunizations. Several recent

studies provide additional data in support of the lack of excess incidence of

rejection and the general safety of vaccinations in organ transplant

recipients.[33-37]

Vaccination coverage of health-care workers, including those caring for

transplant patients, is often suboptimal as well.[38] The 2007 National Patient

Safety Goals of the Joint Commission (http://www.jointcommission.org) includes

" Reduce influenza and pneumococcal disease " as Goal #10. It is an excellent time

to put systems in place for vaccination of solid organ transplant recipients and

candidates according to established guidelines. In addition, these guidelines

should be revised as new vaccines are licensed and additional information

becomes available.

FULL TEXT: http://www.medscape.com/viewarticle/569198?src=mp

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