Live vaccines after pediatric solid organ transplant: Proceedings of a consensus meeting, 2018

Abstract

Growing evidence suggests receipt of live‐attenuated viral vaccines after solid organ transplant (SOT) has occurred and is safe and needed due to lapses in herd immunity. A 2‐day consortium of experts in infectious diseases, transplantation, vaccinology, and immunology was held with the objective to review evidence and create expert recommendations for clinicians when considering live viral vaccines post‐SOT. For consideration of VV and MMR post‐transplant, evidence exists only for kidney and liver transplant recipients. For MMR vaccine post‐SOT, consider vaccination during outbreak or travel to endemic risk areas. Patients who have received antiproliferative agents (eg. mycophenolate mofetil), T cell–depleting agents, or rituximab; or have persistently elevated EBV viral loads, or are in a state of functional tolerance, should be vaccinated with caution and have a more in‐depth evaluation to define benefit of vaccination and net state of immune suppression prior to considering vaccination. MMR and/or VV (not combined MMRV) is considered to be safe in patients who are clinically well, are greater than 1 year after liver or kidney transplant and 2 months after acute rejection episode, can be closely monitored, and meet specific criteria of “low‐level” immune suppression as defined in the document.

A community divided: Post‐transplant live vaccine practices among Society of Pediatric Liver Transplantation (SPLIT) centers

“…Recommendations regarding the use of live viral vaccines after pediatric solid organ transplantation are evolving. 13,14 Historically, 18 Children with chronic liver disease often have suboptimal responses to vaccines. [19][20][21] In a study by Funoki et al of children undergoing liver transplant, the seropositivity rates after live vaccination pre-liver transplant were 47% for measles, 49% for mumps, and 68% for varicella.…”

“…13 In their consensus report, they recommend consideration of live vaccine administration to liver transplant recipients susceptible to measles and/or varicella if doing well one-year post-transplantation and on "low-level immune suppression." 13 Additionally, in April of 2019, the AST ID COP revised their guidelines for immunization of immunocompromised solid organ transplant recipients to state that "MMR and varicella vaccination may be administered in carefully selected patients with appropriate education and close follow-up." 14 In light of these changing recommendations and the recent resurgence of measles infections across the globe increasing risk to susceptible transplant recipients, 15,16 we sought to understand current post-transplant live vaccine immunization practices among US and Canadian pediatric liver transplant centers.…”

Varicella infection following vaccination in a pediatric kidney transplant recipient

“…Along these lines, a 2‐day international, multispecialty consortium of experts from pediatric infectious diseases, immunology, pharmacy, and transplantation was held in February 2018. The consensus recommendations resulting from this meeting were recently published . According to these recommendations, patients are classified into three groups: those who should have vaccination deferred, those who should proceed with vaccination, and those who should only be vaccinated with caution.…”

“…Of note, any patient who has received MMF falls into the group that should be vaccinated with caution, and only after further immunologic assessment. This is due to the higher rates of infectious complications in those who have received MMF as compared to other regimens and the fact that patients who have received MMF only make up a small percentage of the published cohort studies of live vaccines after transplantation . Unfortunately, this further immunologic assessment has yet to be fully defined.…”

“…Criteria to determine which patients should receive these vaccines need to be evaluated before their use after transplant becomes routine. In situations where they are given, recipients and their families should be advised to seek prompt medical attention for any new onset rash or fever higher than 38°C within at least 4 weeks following live viral vaccination, and practitioners should ideally have a minimum of one telephone contact with the patient's caregivers at 3‐4 weeks after vaccination to inquire about any significant symptoms . In addition, patients and their primary care providers should be counseled to avoid live viral vaccines until specifically cleared to receive them by their transplant team.…”