Immunization Key for Patients on Transplant List

SEATTLE — Liver transplant candidates, along with members of their households, should receive all recommended vaccines well before transplantation.

It is important that transplant candidates are vaccinated early in the course of their disease because the response to many vaccines is decreased when the patient is in organ failure, said Hugo Vargas, M.D., at the American Transplant Congress.

“We really need to target patients before they are put on the waiting list for a transplant,” explained Dr. Vargas of the division of transplantation medicine at the Mayo Clinic, Scottsdale, Ariz. “We need to target cirrhotic patients and prevent the development of hepatitis and pneumonia.”

Ideally, vaccination status should be reviewed during the patient's first clinic visit, and a vaccine strategy should be developed at that time.

It is especially important that live vaccines, such as varicella, be administered before transplantation is performed as they cannot be given afterward, said Dr. Vargas.

“You want to know the patient's history, what they are at risk for, and then check their vaccination status,” he explained. “It is important to find out who lives in the household. Are there children? Have they been immunized? Are there any live vaccines needed for the patient or the household?”

Two of the most important vaccines for a liver transplant candidate are hepatitis A (HAV) and hepatitis B (HBV). There is strong evidence that HAV can worsen outcomes in this population, and morbidity can be as much as 50 times higher with HAV and HBV coinfection.

Some data suggest that mortality for patients infected with acute HAV is 23% higher than for those without hepatitis, and HAV can sometimes cause fulminant liver disease.

Immunization against HBV is also important. However, the response rate to the vaccine is low when chronic liver disease is present.

“My recommendation is to identify if your patients are infected, and if they are seronegative, you should schedule a vaccine,” Dr. Vargas said, “because once the patient has been transplanted, the response is very poor.”

Patients with cirrhosis are at increased risk for pneumonia, and the Centers for Disease Control and Prevention recommends that this population be vaccinated for pneumonia. Adult patients should be given the pneumococcal polysaccharide 23-valent vaccine, which offers protection against Streptococcus pneumoniae, the most common cause of adult community-acquired and nursing home-acquired pneumonia. The vaccine needs to be repeated after 5 years if the patient is younger than 65.

Certain individuals, such as those in the military, travelers to high-risk areas, and college freshmen living on campus are also candidates for the meningococcal vaccine, which protects against meningitis caused by Neisseria meningitidis.

Dr. Vargas also pointed out the importance of getting vaccinated annually for influenza A, with the injectable formulation; patients with cirrhosis, however, will need two injections to achieve an 80% response.

“Overall, the strategy needs to consider the vaccination status not only of the patient, but of the family and health care workers as well,” he said.

SEATTLE — Liver transplant candidates, along with members of their households, should receive all recommended vaccines well before transplantation.

It is important that transplant candidates are vaccinated early in the course of their disease because the response to many vaccines is decreased when the patient is in organ failure, said Hugo Vargas, M.D., at the American Transplant Congress.

“We really need to target patients before they are put on the waiting list for a transplant,” explained Dr. Vargas of the division of transplantation medicine at the Mayo Clinic, Scottsdale, Ariz. “We need to target cirrhotic patients and prevent the development of hepatitis and pneumonia.”

Ideally, vaccination status should be reviewed during the patient's first clinic visit, and a vaccine strategy should be developed at that time.

It is especially important that live vaccines, such as varicella, be administered before transplantation is performed as they cannot be given afterward, said Dr. Vargas.

“You want to know the patient's history, what they are at risk for, and then check their vaccination status,” he explained. “It is important to find out who lives in the household. Are there children? Have they been immunized? Are there any live vaccines needed for the patient or the household?”

Two of the most important vaccines for a liver transplant candidate are hepatitis A (HAV) and hepatitis B (HBV). There is strong evidence that HAV can worsen outcomes in this population, and morbidity can be as much as 50 times higher with HAV and HBV coinfection.

Some data suggest that mortality for patients infected with acute HAV is 23% higher than for those without hepatitis, and HAV can sometimes cause fulminant liver disease.

Immunization against HBV is also important. However, the response rate to the vaccine is low when chronic liver disease is present.

“My recommendation is to identify if your patients are infected, and if they are seronegative, you should schedule a vaccine,” Dr. Vargas said, “because once the patient has been transplanted, the response is very poor.”

Patients with cirrhosis are at increased risk for pneumonia, and the Centers for Disease Control and Prevention recommends that this population be vaccinated for pneumonia. Adult patients should be given the pneumococcal polysaccharide 23-valent vaccine, which offers protection against Streptococcus pneumoniae, the most common cause of adult community-acquired and nursing home-acquired pneumonia. The vaccine needs to be repeated after 5 years if the patient is younger than 65.

Certain individuals, such as those in the military, travelers to high-risk areas, and college freshmen living on campus are also candidates for the meningococcal vaccine, which protects against meningitis caused by Neisseria meningitidis.

Dr. Vargas also pointed out the importance of getting vaccinated annually for influenza A, with the injectable formulation; patients with cirrhosis, however, will need two injections to achieve an 80% response.

“Overall, the strategy needs to consider the vaccination status not only of the patient, but of the family and health care workers as well,” he said.

SEATTLE — Liver transplant candidates, along with members of their households, should receive all recommended vaccines well before transplantation.

It is important that transplant candidates are vaccinated early in the course of their disease because the response to many vaccines is decreased when the patient is in organ failure, said Hugo Vargas, M.D., at the American Transplant Congress.

“We really need to target patients before they are put on the waiting list for a transplant,” explained Dr. Vargas of the division of transplantation medicine at the Mayo Clinic, Scottsdale, Ariz. “We need to target cirrhotic patients and prevent the development of hepatitis and pneumonia.”

Ideally, vaccination status should be reviewed during the patient's first clinic visit, and a vaccine strategy should be developed at that time.

It is especially important that live vaccines, such as varicella, be administered before transplantation is performed as they cannot be given afterward, said Dr. Vargas.

“You want to know the patient's history, what they are at risk for, and then check their vaccination status,” he explained. “It is important to find out who lives in the household. Are there children? Have they been immunized? Are there any live vaccines needed for the patient or the household?”

Two of the most important vaccines for a liver transplant candidate are hepatitis A (HAV) and hepatitis B (HBV). There is strong evidence that HAV can worsen outcomes in this population, and morbidity can be as much as 50 times higher with HAV and HBV coinfection.

Some data suggest that mortality for patients infected with acute HAV is 23% higher than for those without hepatitis, and HAV can sometimes cause fulminant liver disease.

Immunization against HBV is also important. However, the response rate to the vaccine is low when chronic liver disease is present.

“My recommendation is to identify if your patients are infected, and if they are seronegative, you should schedule a vaccine,” Dr. Vargas said, “because once the patient has been transplanted, the response is very poor.”

Patients with cirrhosis are at increased risk for pneumonia, and the Centers for Disease Control and Prevention recommends that this population be vaccinated for pneumonia. Adult patients should be given the pneumococcal polysaccharide 23-valent vaccine, which offers protection against Streptococcus pneumoniae, the most common cause of adult community-acquired and nursing home-acquired pneumonia. The vaccine needs to be repeated after 5 years if the patient is younger than 65.

Certain individuals, such as those in the military, travelers to high-risk areas, and college freshmen living on campus are also candidates for the meningococcal vaccine, which protects against meningitis caused by Neisseria meningitidis.

Dr. Vargas also pointed out the importance of getting vaccinated annually for influenza A, with the injectable formulation; patients with cirrhosis, however, will need two injections to achieve an 80% response.

“Overall, the strategy needs to consider the vaccination status not only of the patient, but of the family and health care workers as well,” he said.