nephrology

1. USEFULNESS OF A SYSTEMATIC APPROACH
AT LISTING FOR VACCINE PREVENTION IN
SOLID ORGAN TRANSPLANTATION
CANDIDATES
BLANCHARD-ROHNER ET AL
AMERICAN JOURNAL OF TRANSPLANTATION (FEB 2019)
-SPEAKER: DR SCIENTHIA
MODERATOR –DR RAHUL GROVER
21/2/2019

2. INTRODUCTION
• Solid organ transplantation (SOT) candidates may not be immune against
potentially vaccine-preventable diseases because of insufficient immunizations
and/or limited vaccine responses.
• Risk factors-co-existing health conditions, lifelong immunosuppression to
prevent rejection, and increased exposure during frequent visits to health care
structures
• Prevention of infections by vaccination is the least invasive and most cost-
effective way to diminish morbidity and mortality in SOT-recipient
• Once on life-long immunosuppression depressing cell-mediated immunity and
antibody production, SOT-recipients may not respond as well to vaccination

3. • SOT-candidates and recipients may not be sufficiently protected because
 insufficient routine immunization
 limited magnitude and duration of vaccine-induced protection in end-stage
diseases
 use of immunosuppressive regimens
• only 25% patients with end-stage organ diseases referred for pre-
transplantation workup had previously been immunised against hepatitis B
despite existing guidelines and only 52% had been vaccinated against seasonal
influenza in the previous two seasons.

4. STUDY DESIGN

5. STUDY POPULATION

8. DEFINITION OF IMMUNITY AGAINST POTENTIALLY
VACCINE-PREVENTABLE DISEASES
Anti
hepatitis A
IgG index
AntiHBs
IgG
Anti
Measles
IgG
Anti VZV
IgG
Anti
tetanus
Toxoid IgG
Levels
required
>10 IU/L >10 IU/L >150IU/L >50IU/L >100IU/L

9. ANTIBODIES TO S. PNEUMONIAE
• Assessed for three representative serogroups contained in the 13-valent conjugate
vaccine (Prevenar 13®, PCV13, Pfizer)
 High immunogenicity (14)
 Moderate immunogenicity (19 )
 and low immunogenicity (23F,).
• Antibody quantification was performed by ELISA using WHO consensus protocol which
includes serum pre-absorption with pneumococcal cell wall- and serotype 22F
polysaccharide and use of 89-SF as a reference for antibody quantification.
• Patients with specific IgG levels ≥0.5 μg/ml to at least two of the three tested serotypes
were empirically considered as “seropositive

10. CATCH UP IMMUNIZATION
• A booster dose given with the hope to maintain immunity around
transplantation
HBV vaccine -anti-HBsAg concentration < 100 UI/l
Tetanus vaccine- anti-tetanus IgG < 500 UI/l
PCV 13 vaccine -serotype-specific antibodies ≥ 0.5 μg/ml for < 2/3
pneumococcal serotypes
One dose of trivalent inactivated seasonal influenza vaccine offered to all
SOT-candidates seen during the influenza season (October to March).

11. • Serology-driven catch-up immunization identified the need for 833 vaccine
doses (3.80 per patient, range 0-10) – in addition to PCV13 ± influenza
vaccines administered at listing. The first of these 833

12. RECOMMENDED VACCINES AFTER
KIDNEY TRANSPLANTATION
• Diphtheria—pertussis–tetanus
• Haemophilus influenza B
• Hepatitis A∗
• Hepatitis B
• Pneumovax
• Inactivated polio
• Influenza types A and B (administer annually)
• Meningococcus: administer if recipient is in high risk
• Typhoid Vi

13. INACTIVATED INFLUENZA VACCINE
Influenza A and B
• Can be given pre- and post tx
• Annually
• All patients who are >3 months post-transplant should receive seasonal influenza vaccine.
• Can be HIGH DOSE (2 doses 5 weeks apart )/STANDARD DOSE- high dose better
immunogenicity and clinical efficacy in elderly people but similar safety profile Natori et al )
• May be administered in the immediate post-transplant period during an outbreak
• Live-attenuated influenza (nasal spray flu vaccine) are cold adapted and should not replicate
at normal body temperature but due to small theoretical risk of replication, not
recommended posttransplant
Haemophilus influenzae type b – can also be given pre- and post tx

14. PNEUMOCOCCAL VACCINE
Pneumococcal conjugate PCV13 Y Y
• 13-valent protein-conjugated vaccine.
• For those who have not received either Pneumococcus vaccine, PCV13 should be administered first,
followed 8 weeks later by PPSV23.
• Patients who have already received 1 dose of PPSV23 should receive PCV13 at least 1 year after PPSV23.
• preferred-the 23-valent plain polysaccharide pneumococcal vaccine (PPSV23) has been associated with
short-term protection and hypo-responsiveness
Pneumococcal polysaccharide PPSV23
• 23-valent polysaccharide. May produce antibodies of higher avidity and also lead to formation of memory B
cell
• Recommended post-transplant if not administered pretransplant.
• Patients who have already received 1 dose of PPSV23 should receive an additional dose 5 years after the
first dose of PPSV23
Adults posttransplant, conjugate vaccines produce a similar immunogenicity profile to polysaccharide vaccines

16. HEPATITIS B
• Recommended post-transplant if not administered pretransplant.
• Anti-HBs–negative SOT candidates should receive the HepB vaccine series. If a
postvaccination anti-HBs concentration of ≥10 mIU/mL is not attained, a second 3-dose
series of HepB vaccine( alternative: 1 dose of HepB vaccine after which anti-HBs is
tested*) should be administered, using standard dose or high dose* for children and
high dose for adolescents* and adults Monitor titers for response to vaccination and
repeat vaccination series if needed.
• A level above 10 mIU/mL is generally taken to be protective, but transplant recipients
with titers less than100 mIU/mL tend to lose them rapidly.
• European Consensus Group suggest booster vaccination at titers below 100 mIU/mL.

17. VARICELLA ZOSTER
• Varicella-live -Should be administered ≥4 weeks before transplant and C/I post Tx
• Two doses should be given 4 weeks apart.
• Seronegative adults should receive one dose of varicella vaccine with serologic testing
postvaccination.
• If seroconversion does not occur, the dose can be repeated once if time permits. Those
who do not seroconvert are candidates for postexposure prophylaxis should this occur
after transplantation.
• blood products such as intravenous immune globulin can interfere with the response to
live vaccines- vaccine should be delayed for 3months after the receipt of blood products.

18. ZOSTER VACCINE
• Herpes zoster virus reactivation can affect up to 20% of SOT patients during their
lifetime .
• Immunization pre-transplantation relies on varicella vaccine if the VZV serology is
negative and shingles vaccine if the patient is seropositive
Zoster-live (Zostavax)
• Contraindicate post Tx
• Should be administered ≥4 weeks before transplant.
Herpes zoster subunit vaccine (HZ/su)-SHINGERIX
• inactivated vaccine against shingles was recently approved by the FDA after two
randomized trials showing clinical efficacy for the prevention of shingles compared with
placebo in adults more than 50 years old and more than 70 years old
• 2 dose schedule -0,2 months

19. Hepatitis A
• Recommended post-transplant if not administered pretransplant.
• For travelers to endemic areas
Diphtheria-tetanus-pertussis
• To be given pre transplant
• Booster every 10 years.
Poliovirus Inactivated polio
• For travelers to endemic areas (e.g., some parts of Asia, Africa).
MMR
• Can be given pre-Tx but contra indicated post TX
Neisseria meningitides
• Recommended for patients with properdin terminal component deficiencies
or receiving eculizumab therapy, or those with functional or anatomic
asplenia.

20. HUMAN PAPILLOMAVIRUS (HPV)
• To be given pre-Tx to nonpregnant female candidates ages 11-26 (BOTH
QUADRIVALENT AND BIVALENT , males ages 11-21 (ONLY
QUADRIVALENT)
• the quadrivalent vaccine can also be used in women up to the age of 45
years
• A three-dose vaccine schedule should be given prior to transplant in those
who meet the indications.
• If all doses are not completed pretransplant, the additional doses can be
resumed starting 3–6 months posttransplant.