Immunizations in Chronic Liver Disease: What Should be Done and What is the Evidence

Abstract

Infections are common in patients with chronic liver disease, especially those with cirrhosis. Patients with advanced liver disease, who develop bacterial infections, are at a substantially higher risk of death. As liver disease progresses, most immunizations lose their effectiveness. Overall, it is important to address immunization needs in patients with chronic liver disease early on, when immunizations are most effective. Inactivated or killed-type vaccinations rather than live, attenuated vaccinations are always preferable in patients with cirrhosis. The influenza vaccination is less effective in patients with cirrhosis and in the early post-liver transplant setting as compared to healthy individuals. The influenza vaccination may prevent hepatic decompensation, but further data are needed to confirm this. Yearly inactivated influenza vaccinations should be provided to those with chronic liver disease. The pneumonia vaccination is less effective in patients with cirrhosis, with a further decline in protective serologies after liver transplantation. Standard guidelines for the administration of Pneumovax23 for immunocompromised hosts apply to patients with chronic liver disease. Chronic liver disease also leads to higher non-response rates to the hepatitis B vaccination. Early-stage chronic liver disease patients should receive conventional hepatitis B series. Cirrhotics benefit from a double-dose hepatitis B vaccination at standard intervals. Hepatitis A superimposed on chronic viral hepatitis or chronic liver disease increases risk of mortality. Hepatitis A vaccination effectiveness wanes in cirrhosis, and should if possible be given before the development of cirrhosis. More data are needed for routine use of herpes zoster and human papillomavirus in chronic liver disease.

Update on prevention, diagnosis, and treatment of chronic hepatitis B

“…Recently, a 2‐dose series given at 0 and 1 months has been approved for adults (HEPLISAV‐B). Sexual and household contacts of HBV‐infected persons who are negative for HBsAg and anti‐HBs should receive HBV vaccination. Newborns of HBV‐infected mothers should receive HBIG and HBV vaccine at delivery and complete the recommended vaccination series. Infants of HBsAg‐positive mothers should undergo postvaccination testing at 9‐15 months of age. HCWs, sexual partners of persons with chronic HBV infection, chronic hemodialysis patients, and immunocompromised persons (including those with HIV) should be tested for their response to the vaccination 1‐2 months after the last dose of vaccine. For nonresponders to the initial vaccine series, a repeat 3‐dose vaccination series is recommended, with a double dose used for immunocompromised patients, including those with cirrhosis Follow‐up testing of vaccine responders is recommended annually for chronic hemodialysis patients. Booster doses or revaccination are not recommended except if anti-HBs remains <10 mIU/mL after initial vaccination of infants born to HBsAg-positive mothers, in HCWs, hemodialysis patients and other individuals who are immunocompromised …”

Promoting a Healthy Lifestyle, Managing Hyperlipidemia, Diabetes Mellitus, Hypertension, and Immunizations in Patients with Cirrhosis

“…These patients are at increased risk of infections, with a higher associated morbidity and mortality [68]. Unfortunately, patients with advanced liver disease may fail to mount a protective immune response to appropriate vaccinations.…”

“…Unfortunately, patients with advanced liver disease may fail to mount a protective immune response to appropriate vaccinations. As a result, it is important to administer vaccination early in the course of chronic liver disease, where possible [68,69]. Furthermore, immunization with live virus vaccines is generally avoided after LT.…”

Sero-prevalence and vaccination status of hepatitis A and hepatitis B among adults with cirrhosis in Sri Lanka: a hospital based cohort study

“…Both HAV and hepatitis B virus (HBV) can cause severe infection in non-immune adults, and can even be fatal in adult patients with cirrhosis. Vaccination against HAV and HBV is, therefore, recommended for non-immune patients with cirrhosis [2]. …”