after live donor renal allotransplantation , all patients are vulnerable for infection . vaccination is a good choice to prevent some infectious disease s but immunosuppressive drugs alter the response

1. Post-transplant vaccinations
By
Salwa Mahmoud Elwasif, MD
Fellow of Internal Medicine and Nephrology
Urology & Nephrology Center,
Mansoura University

2. Why………?

3. What are preventable diseases?
The only diseases could be avoided
is the infectious diseases.. Infection
Control

4. Journey of renal transplantation

5. Why….?
• Kidney transplant recipients are at increased risk of
developing infections including vaccine-preventable
diseases.
• Some vaccines may not be beneficial whereas others
could even be harmful to kidney transplant recipients.

6. • Prevention of infection is of paramount
importance to the increasing population of solid
organ transplant recipients.
Hibberd and Rubin, 1994

7. • Infection in these patients results in excessive
morbidity and mortality, and antimicrobial therapy is
often less effective than in the immunocompetent
host.
Avery and Michaels, 2008

8. Immunogenicity
• The risk of acquiring infection and the inability to prevent
infection by immunization are directly related to the
patient's "net state of immunosuppression.“
• The greater the degree of immunosuppression, the less
likely the patient is to respond to immunization.
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9. Immunogenicity
The factors affecting response:
• the underlying disease (eg, renal or hepatic insufficiency),
• the presence of allograft rejection
• the immunosuppressive therapy administered after
transplantation.
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10. So….,
• Although immunization appears to be an
obvious way to prevent infection, many
immunocompromised patients are unable to
mount protective immune responses.

11. Guidelines

12. Guidelines
• In 2013, the American Society of Transplantation (AST)
updated the guidelines for vaccination of pediatric and
adult solid organ transplant candidates and recipients
as well as healthcare workers, household contacts, and
other close contacts of these patients.
Danziger et al, 2013

13. Guidelines
• the Infectious Diseases Society of America
(IDSA) published guidelines for vaccination of
immunocompromised hosts, including solid
organ transplant recipients .
Rubin et al, 2014

14. Guidelines
• The United States Advisory Committee on
Immunization Practices (ACIP) also includes
immunocompromised hosts in their
recommendations.
Chong and Avery, 2017

15. Guidelines for vaccination in
kidney transplant recipients
1. Kidney transplant recipients should receive age-appropriate
inactivated vaccinations as recommended for general
population.
2. Kidney transplant recipients should not receive live
vaccines.
If a patient has received a live vaccine, the transplant should
be delayed by at least 4 weeks since the time of
administration

16. Guidelines for vaccination in kidney
transplant recipients
3. it is best to wait until the first 3–6 months after kidney
transplantation, the period of intense immunosuppression,
before attempting vaccination.
However, inactivated influenza vaccination can be
administered as early as 1 month after kidney transplant to
time it before onset of the flu season

17. Guidelines for vaccination in
kidney transplant recipients
• 4. Kidney transplant patients should receive ancillary
inactivated vaccines based on the risk factors for the
respective disease and the propensity to develop these
rare infections, especially for vaccines that are neither
routinely recommended for general population nor
specifically in transplant recipients.

18. Guidelines for vaccination in kidney
transplant recipients
• There is no evidence to associate solid organ rejection
episodes to vaccination, even with live or adjuvanted
vaccines .
• In contrast, there is an association between infection
including VPD as e.g. influenza and rejection episodes .

19. Guidelines for vaccination in kidney
transplant recipients
• Some agents, such as mycophenolate mofetil, seem to have a
strong negative effect on the ability to mount antibody
responses to vaccination .
• Similarly, it is not recommended to immunize during an
episode of rejection requiring intensification of
immunosuppression.

20. Rationale and Supporting Evidence
• The pre transplant vaccination history and the
seroprotective status would affect the post transplant
vaccination strategies.
• Hence, detailed vaccination history should be
obtained in all kidney transplant recipients at the first
visit after kidney transplantation to plan the
vaccination schedule if it is not already available.

21. Type of vaccine
• Live attenuated vaccines pose considerable risk
• Live virus vaccines should be administered as early in the
course of chronic kidney disease (CKD) as possible.
• After administration of a live attenuated vaccine, a mandatory
minimum waiting period of 4 weeks is necessary before using
immunosuppression.

22. Guidelines for vaccination in
kidney transplant recipients
• Under immunosuppression not only could live vaccine
strains proliferate unchecked causing vaccine-induced
diseases but also the immune response of recipients to the
vaccines could be suboptimal, rendering vaccination
ineffective.

23. Monitoring immune response to
vaccination
• Wherever possible, seroconversion should be
documented after 4 weeks of completing the course
of immunization.
• Monitoring cellular immunity for protection against
infections is under research.

24. Vaccination of health care workers
and household contacts
• Strategy to vaccinate household contacts and pets with
vaccines for preventable diseases.
• Vaccine-preventable diseases such as Hepatitis B,
pneumococcal disease, and especially influenza vaccine
should be offered to household contacts.
• In general, inactivated vaccines are preferred for
vaccination of household contacts.

25. Vaccination of health care workers
and household contacts
• Administration of live vaccines to household contacts can
result in viral shedding,.
• In case only a live attenuated vaccine is available, viral
shedding should be considered and preferably the household
contacts who have received them should exercise precaution
as well as infection prevention measures for the first 2 weeks,
when viral shedding is likely to be at its peak.

26. Vaccination of health care workers
and household contacts
• Administration of oral polio vaccine to children in the
recipient's household, which can result in virus shedding.
• However, so far, there have been no documented reports of
vaccine-induced poliomyelitis among transplant recipients.

27. Pre-transplant period
• Evaluation and documentation of the immunization status
and the estimate of protection against VPD is of paramount
importance
• It relies on the documentation of immunizations received
(immunization records) and on vaccine-induced immunity
(serological analyses).

28. Vaccination records
• This documentation must be available and reviewed at first contact
in the transplantation centre and should be considered compulsory
for listing.
• Note that pre-transplant documentation of completed
immunizations is the strongest indicator for protection against VPD
.
• This documentation should include a documentation of disease
history where relevant, for example for hepatitis B or varicella
infections.

29. Immunity against VPD (serology):
• Documentation of immunity against all VPD should be
achieved before transplantation.
• The documentation of the vaccination status in SOT
recipients as well as in SOT candidates should be
completed by the determination of specific antibody titres.

30. Immunity against VPD (serology):
Determination of antibody levels may be helpful when:
• it is unclear whether there is immunity against particular VPD
• The need for a booster immunization (e.g. tetanus, hepatitis
B) must be assessed
• The response after completed primary or a booster
immunization needs to be evaluated
• it is desirable to assess the likely (long term) protection.

31. Immunity against VPD (serology):
• Is best when the level is measured 1–3 months after
completion of a primary immunization series or a booster dose.
• Immunity from vaccines/infections that confer sustained
protection (e.g. measles, VZV) may be checked at all times.
• Antibodies to hepatitis A and yellow fever also indicate
immunity.

32. Immunity against VPD (serology):
• Specific antibody levels against other VPD such
as pertussis, mumps, HPV, meningococcal
infection or influenza have either not been
characterized, are not established, not available,
not required to demonstrate protection or lack a
correlate for protection.

35. Immunization for Healthcare
Workers and Close Contacts of
Transplant Recipients
• Healthcare workers and close contacts of transplant recipients
should be immunized against all vaccine preventable diseases.
• However, viral shedding has been reported after the
administration of some live attenuated vaccines, so frequent
handwashing should be maintained for a two-week period
following vaccination with these types of vaccines .

36. Conclusion
• Kidney transplant recipients have a higher risk of infection esp.
vaccine-preventable diseases than the general population.
• Although the immune response may be suboptimal in transplant
recipients, immunization is crucial to decreasing the morbidity
and mortality from vaccine-preventable diseases in these
patients.
• Whenever possible, physicians should consider scheduling
vaccination early in the course of end-stage organ disease and
postponing the transplantation .

37. Conclusion
• Live attenuated vaccines are generally contraindicated after
transplantation.
• Vaccination of health care workers and close contacts of
transplant patients is important to protect
immunocompromised patients from diseases.

38. • All infectious diseases are avoidable
• Not all infectious diseases have vaccines

39. Thank you