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Condran B, Kervin M, Burton C, Blydt-Hansen TD, Morris SK, Sadarangani M, Otley A, Yong E, Mitchell H, Bettinger JA, Top KA. Parent and healthcare provider views of live varicella vaccination of pediatric solid organ transplant recipients. Pediatr Transplant 2023; 27:e14609. [PMID: 37746885 DOI: 10.1111/petr.14609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/28/2023] [Accepted: 09/01/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Live attenuated varicella vaccine (LAVV) has historically been contraindicated in children who are immunocompromised due to solid organ transplant (SOT) because of safety concerns. Recently, clinical guidelines were developed that support post-transplant varicella vaccination in selected SOT recipients based on emerging evidence of LAVV safety. This qualitative study sought to explore barriers and facilitators to implementing the new guidelines, as well as acceptability of LAVV among healthcare providers (HCPs) and parents. METHODS HCPs and parents of transplant recipients were recruited from four sites using purposive sampling. Data from semi-structured interviews were analyzed using an Interpretive Description approach that incorporated data from the interviews, academic knowledge and clinical experience, and drew from Grounded Theory and Thematic Analysis. The theoretical framework used was Adaptive Leadership. RESULTS Thirty-four participants (16 HCPs and 18 parents) were included in the analysis. Parents developed skills in adaptive leadership that included strategies to protect their child against infectious diseases. Foundational information that live vaccines were absolutely contraindicated post-transplant "stuck" with parents and led them to develop strategies other than vaccination to keep their child safe. Some parents struggled to understand that information previously presented as a certainty (contraindication of LAVV) could change. Their approach to adaptive leadership informed their appraisal of the new vaccination guidelines and willingness to accept vaccination. CONCLUSIONS HCPs should adopt a family-centered approach to communicating changing guidelines that considers parents' approach to adaptive leadership and discusses the changing nature of medical evidence. Trust between HCPs and parents can facilitate these conversations.
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Affiliation(s)
- Brian Condran
- Canadian Center for Vaccinology, IWK Health, Halifax, Nova Scotia, Canada
| | - Melissa Kervin
- Canadian Center for Vaccinology, IWK Health, Halifax, Nova Scotia, Canada
| | - Catherine Burton
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shaun K Morris
- Clinical Public Health and Centre for Vaccine Preventable Diseases, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases and Child Health Evaluative Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Manish Sadarangani
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Anthony Otley
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Hana Mitchell
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Julie A Bettinger
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Karina A Top
- Canadian Center for Vaccinology, IWK Health, Halifax, Nova Scotia, Canada
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
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2
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Kamei K. Live attenuated vaccines in patients receiving immunosuppressive agents. Pediatr Nephrol 2023; 38:3889-3900. [PMID: 37076756 PMCID: PMC10115603 DOI: 10.1007/s00467-023-05969-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 04/21/2023]
Abstract
The use of live attenuated vaccines in patients with immunosuppressive agents is contraindicated in package inserts and guidelines in Japan and other countries. However, patients receiving immunosuppressants have a high risk of infectious disease becoming severe, and the necessity to prevent infectious disease is high. To date, 2,091 vaccinations have been reported in 25 reports of live attenuated vaccines in people receiving immunosuppressants. Twenty-three patients (1.1%) became infected with the virus strain used in the vaccine, which was varicella virus in 21 patients. No reports have described life-threatening complications. A prospective study at the National Center for Child Health and Development conducted under certain immunological conditions (CD4 cell count ≥ 500/mm3, stimulation index of lymphocyte blast transformation by phytohemagglutinin (PHA) ≥ 101.6, serum immunoglobulin G ≥ 300 mg/dL) confirmed the serological effectiveness and safety. The evidence suggests that live attenuated vaccines can be used even in combination with immunosuppressants. Further evidence must be gathered and immunological criteria investigated to determine the conditions for safe use. Depending on the results of these investigations, the wording in package inserts and guidelines may need to be revised.
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Affiliation(s)
- Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan.
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3
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Piché-Renaud PP, Yue Lee E, Ji C, Qing Huang JY, Uleryk E, Teoh CW, Morris SK, Top KA, Upton JEM, Vyas MV, Allen UD. Safety and immunogenicity of the live-attenuated varicella vaccine in pediatric solid organ transplant recipients: A systematic review and meta-analysis. Am J Transplant 2023; 23:1757-1770. [PMID: 37321454 DOI: 10.1016/j.ajt.2023.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/17/2023]
Abstract
This study aimed to synthesize the available evidence on the immunogenicity, safety, and effectiveness of live-attenuated varicella vaccine in solid organ transplant recipients. Medline and EMBASE were searched using predefined search terms to identify relevant studies. The included articles reported varicella vaccine administration in the posttransplant period in children and adults. A pooled proportion of transplant recipients who seroconverted and who developed vaccine-strain varicella and varicella disease was generated. Eighteen articles (14 observational studies and 4 case reports) were included, reporting on 711 transplant recipients who received the varicella vaccine. The pooled proportion was 88.2% (95% confidence interval 78.0%-96.0%, 13 studies) for vaccinees who seroconverted, 0% (0%-1.2%, 13 studies) for vaccine-strain varicella, and 0.8% (0%-4.9%, 9 studies) for varicella disease. Most studies followed clinical guidelines for administering live-attenuated vaccines, with criteria that could include being at least 1 year posttransplant, 2 months postrejection episode, and on low-dose immunosuppressive medications. Varicella vaccination in transplant recipients was overall safe in the included studies, with few cases of vaccine-strain-induced varicella or vaccine failure, and although it was immunogenic, the proportion of recipients who seroconverted was lower than that seen in the general population. Our data support varicella vaccination in select pediatric solid organ transplant recipients.
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Affiliation(s)
- Pierre-Philippe Piché-Renaud
- Division of Infectious Diseases, the Hospital for Sick Children, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Erika Yue Lee
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Clinical Immunology and Allergy, St. Michael's Hospital, Toronto, Ontario, Canada; Eliot Phillipson Clinician Scientist Training Program, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Ji
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto Western Family Health Team, University Health Network, Toronto, Ontario, Canada
| | - Jenny Yu Qing Huang
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Chia Wei Teoh
- Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shaun K Morris
- Division of Infectious Diseases, the Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Centre for Global Child Health, the Hospital for Sick Children, Toronto, Ontario, Canada; Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Karina A Top
- Departments of Pediatrics and Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Julia E M Upton
- Division of Immunology and Allergy, Department of Paediatrics, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Manav V Vyas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Upton D Allen
- Division of Infectious Diseases, the Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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4
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Alimohammadi M, Moosazadeh M, Mardomi A, Mousavi T. Seroprevalence of VZV IgG antibody in kidney transplant recipients: A systematic and meta-analysis review. Transpl Immunol 2022; 75:101730. [DOI: 10.1016/j.trim.2022.101730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/20/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
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Daly KP, Sharma TS. Experience with Live Attenuated Varicella Vaccination in Pediatric Heart Transplant Recipients: Considering a New Path Forward. J Heart Lung Transplant 2022; 41:1027-1028. [DOI: 10.1016/j.healun.2022.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 03/27/2022] [Indexed: 10/18/2022] Open
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6
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Dipchand AI, Seifert-Hansen M. Early Experience with Varicella Vaccination in Pediatric Heart Transplant Recipients. J Heart Lung Transplant 2022; 41:1023-1026. [DOI: 10.1016/j.healun.2022.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/04/2022] [Accepted: 02/05/2022] [Indexed: 12/15/2022] Open
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Filippidis P, Vionnet J, Manuel O, Mombelli M. Prevention of viral infections in solid organ transplant recipients in the era of COVID-19: a narrative review. Expert Rev Anti Infect Ther 2021; 20:663-680. [PMID: 34854329 DOI: 10.1080/14787210.2022.2013808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION In solid organ transplant (SOT) recipients, viral infections are associated with direct morbidity and mortality and may influence long-term allograft outcomes. Prevention of viral infections by vaccination, antiviral prophylaxis, and behavioral measures is therefore of paramount importance. AREAS COVERED We searched Pubmed to select publications to review current preventive strategies against the most important viral infections in SOT recipients, including SARS-CoV-2, influenza, CMV, and other herpesvirus, viral hepatitis, measles, mumps, rubella, and BK virus. EXPERT OPINION The clinical significance of the reduced humoral response following mRNA SARS-CoV-2 vaccines in SOT recipients still needs to be better clarified, in particular with regard to the vaccines' efficacy in preventing severe disease. Although a third dose improves immunogenicity and is already integrated into routine practice in several countries, further research is still needed to explore additional interventions. In the upcoming years, further data are expected to better delineate the role of virus-specific cell mediated immune monitoring for the prevention of CMV and potentially other viral diseases, and the role of the letermovir in the prevention of CMV in SOT recipients. Future studies including clinical endpoints will hopefully facilitate the integration of successful new influenza vaccination strategies into clinical practice.
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Affiliation(s)
| | - Julien Vionnet
- Transplantation Center, Lausanne University Hospital, Lausanne, Switzerland.,Service of Gastroenterology and Hepatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Oriol Manuel
- Service of Infectious Diseases, Lausanne University Hospital, Lausanne, Switzerland.,Transplantation Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Matteo Mombelli
- Service of Infectious Diseases, Lausanne University Hospital, Lausanne, Switzerland.,Transplantation Center, Lausanne University Hospital, Lausanne, Switzerland.,Service of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
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8
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Gumm AJ, Lerret S, Zeman M, Rueter J, Huppler AR, Khan Z, Telega G, Vitola B. Quality improvement project to improve vaccinations in the pediatric liver transplant population. Pediatr Transplant 2021; 25:e14076. [PMID: 34185930 DOI: 10.1111/petr.14076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 04/07/2021] [Accepted: 06/12/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES A quality improvement approach was used to increase pediatric liver transplant recipient live and inactive vaccination rates by assessing titers and recommending vaccinations. METHODS A new screening and immunization process for both live and inactive vaccines was discussed with families at their annual visit. Antibody titers for varicella, measles, mumps, rubella, Haemophilus influenzae type B, hepatitis A, and hepatitis B were obtained. Specific criteria were developed for live virus vaccination candidacy. Vaccines were recommended based on patient titers and vaccination candidacy criteria. Surveillance for adverse effects to live vaccines was performed. Repeat titers were obtained approximately 1-month post-vaccine administration. RESULTS After PDSA cycle 1, 99% (71/72) of pediatric liver transplant patients had titers obtained. Live vaccines were recommended for 32 patients and 16 (50%) were vaccinated. Inactive vaccines were recommended to 64 patients, and 31 (48%) were vaccinated. Eight of 13 (62%) patients with follow-up titers achieved immunity for inactive vaccines. Zero patients had an adverse reaction to any live vaccine. Ten of 12 (83%) patients with follow-up titers achieved immunity from live vaccines. The most common barriers to receive live vaccines included not scheduling appointment with primary care provider (n = 3) and "non-vaccinators" (n = 3). CONCLUSIONS Administering live and inactive vaccines to select pediatric liver transplant patients appears to be safe and effective in our studied population. For PDSA cycle 2, we will continue our current practice and consider offering vaccines in transplant clinic, since this was a barrier to vaccination identified during PDSA cycle 1.
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Affiliation(s)
- Alexis J Gumm
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Stacee Lerret
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Matthew Zeman
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Janelle Rueter
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anna R Huppler
- Divisions of Pediatric Infectious Disease, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zahida Khan
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Grzegorz Telega
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bernadette Vitola
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
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9
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Kamei K, Miyairi I, Shoji K, Arai K, Kawai T, Ogura M, Ishikura K, Sako M, Nakamura H. Live attenuated vaccines under immunosuppressive agents or biological agents: survey and clinical data from Japan. Eur J Pediatr 2021; 180:1847-1854. [PMID: 33523302 DOI: 10.1007/s00431-021-03927-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/16/2020] [Accepted: 01/01/2021] [Indexed: 11/26/2022]
Abstract
UNLABELLED Live attenuated vaccines are contraindicated for patients on immunosuppressive agents or biological agent, except for live attenuated varicella vaccine, although previous reports showed their effectiveness and safety. This study is the nationwide cross-sectional research about the current utilization of live attenuated vaccines for patients on immunosuppressive agents or biological agents in Japan. We sent questionnaires to pediatric centers and examined whether each institution offered live attenuated vaccines to patients with immunosuppressive agents or biological agents (institutional research). We also examined adverse events associated with live attenuated vaccines between 2013 and 2017 (patient research). In the institutional research, 46 out of 334 institutions (13.8%) administered live attenuated vaccines to patients receiving immunosuppressive agents. In contrast, only six out of 270 institutions (2.2%) administered live attenuated vaccines to patients receiving biological agents. However, 66.3% of physicians answered that patients receiving immunosuppressive agents should be immunized with live attenuated vaccines, and only 7.0% disagreed with them. In the patient research, data for 781 patients were collected. Vaccine-associated infections were observed in only two patients (0.3%), both of whom had varicella, although they recovered promptly. No life-threatening adverse events were noted. CONCLUSION In pediatric centers, the demand for live attenuated vaccines in patients receiving immunosuppressive agents was high and most physicians think they should be immunized. Immunization with live attenuated vaccines appeared safe in patients receiving immunosuppressive agents, although further studies are needed for patients receiving biological agents What is known: • Live attenuated vaccines (LAV) are generally contraindicated for patients on immunosuppressive agents (IS) or biological agents (BA), except for live attenuated varicella vaccine, as immunocompromised patients are at greater risk for serious viral infection from the vaccine strains. • Viral infections, such as measles and varicella, cause serious complications in children receiving IS. • Several previous reports showed that LAV is relatively effective and safe for patients receiving IS. What is new: • In Japan, the demand for LAV in patients receiving IS was high, and most physicians hoped they should be immunized. • Vaccine-associated infection is rarely observed in patients with IS after LAV administration. • Immunization with LAV appeared safe in patients receiving IS. TRIAL REGISTRATION University Hospital Medical Information Network (UMIN). TRIAL REGISTRATION NUMBER UMIN000029176.Date of registration: 2017/09/19.
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Affiliation(s)
- Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Isao Miyairi
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Kensuke Shoji
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Katsuhiro Arai
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Toshinao Kawai
- Division of Immunology, National Center for Child Health and Development, Tokyo, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
- Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Japan
| | - Mayumi Sako
- Division for Clinical Trials, Department of Clinical Research Promotion, Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hidefumi Nakamura
- Department of Development Strategy, Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
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10
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Groeneweg L, Loeffen YGT, Versluys AB, Wolfs TFW. Safety and efficacy of early vaccination with live attenuated measles vaccine for hematopoietic stem cell transplant recipients and solid organ transplant recipients. Vaccine 2021; 39:3338-3345. [PMID: 33992440 DOI: 10.1016/j.vaccine.2021.04.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Vaccination with the live attenuated measles vaccine is currently recommended two years after hematopoietic stem cell transplantation (HSCT) and generally contraindicated after solid organ transplantation (SOT) due to safety concerns. However, in the last few years new data on the administration of the measles vaccine to HSCT recipients less two years post-transplantation and to SOT recipients have become available. This new data may change current guidelines and practices. The objective of this review is to provide an overview of the current data on the safety and efficacy of early measles vaccination for HSCT- and SOT recipients. METHOD PubMed and EMBASE were searched from the earliest date available through October 2019 to identify all research that reported on the safety and efficacy of measles vaccination after SOT or less than two years after HSCT. RESULTS A total of ten studies was included in this review. In the six studies that evaluated the efficacy of measles vaccination after SOT, seroconversion rates ranged from 41 to 100% after one dose and 73 to 100% after two doses. In the four studies that evaluated the efficacy of measles vaccination less than two years after HSCT, seroconversion rates ranged from 33 to 100% after one dose and 100% after two doses. In all studies, the administration of the measles vaccine after transplantation was considered to be safe. There were no cases of infection with the attenuated vaccine strain, and there were no adverse events related to the vaccination. CONCLUSION Data on the administration of the measles vaccine after SOT and less than two years after HSCT is scarce. However, the current data available suggest that it is efficacious and well tolerable. Therefore, early measles vaccination could be considered in selected groups of SOT- and HSCT recipients during increased measles transmission or an outbreak setting.
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Affiliation(s)
- Leonie Groeneweg
- University of Utrecht & Wilhelmina Children's Hospital, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Yvette G T Loeffen
- Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA Utrecht, the Netherlands
| | - Anne Birgitta Versluys
- Department of Blood and Marrow Transplantation, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Tom F W Wolfs
- Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA Utrecht, the Netherlands.
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11
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Evaluation of Recombinant Herpes Zoster Vaccine for Primary Immunization of Varicella-seronegative Transplant Recipients. Transplantation 2021; 105:2316-2323. [PMID: 33528118 DOI: 10.1097/tp.0000000000003621] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Immunization of VZV-seronegative solid organ transplant (SOT) patients using the live-attenuated varicella vaccine is generally contraindicated, leaving no widely applicable immunization option. The recombinant subunit herpes zoster vaccine (RZV) is indicated for VZV seropositive persons to prevent shingles but could potentially also protect VZV-seronegative persons against varicella. We performed a safety and immunogenicity evaluation of RZV in VZV-seronegative SOT recipients as an option for protection. METHODS VZV-seronegative adult SOT patients with no history of varicella/shingles vaccine or disease were given 2 doses of RZV vaccine 2-6 months apart. Blood was drawn prevaccination (V1), prior to the second dose (V2) and 4 weeks after second dose (V3). Humoral (anti-gE) and cell-mediated immunity was evaluated, with polyfunctional cells defined as cells producing ≥2 cytokines. RESULTS Among 31 eligible VZV-seronegative SOT patients screened, 23 were enrolled. Median age was 38 years and median time since transplant procedure was 38 years. The most frequent transplant types were liver (35%) and lung (30%). Median anti-gE levels significantly increased from V1 to V3 (p=0001) and V2 to V3 (p<0001), even though only 55% had a positive seroresponse. Median polyfunctional CD4 T-cells counts increased from V1 to V2 (54/10 vs 104/10 cells; p=0041), and from V2 to V3 (380/10; p=0002). Most adverse events were mild with no rejection episodes. CONCLUSION RZV was safe and elicited significant humoral and cellular responses in VZV-seronegative SOT patients, and has the potential to be considered as a preventive strategy against primary varicella.
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12
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Pittet LF, Danziger-Isakov L, Allen UD, Ardura MI, Chaudhuri A, Goddard E, Höcker B, Michaels MG, Van der Linden D, Green M, Posfay-Barbe KM. Management and prevention of varicella and measles infections in pediatric solid organ transplant candidates and recipients: An IPTA survey of current practice. Pediatr Transplant 2020; 24:e13830. [PMID: 32964637 DOI: 10.1111/petr.13830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/14/2020] [Accepted: 07/28/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Varicella and measles infections can be life-threatening after solid organ transplantation (SOT) but may be preventable with live-attenuated vaccines (LAV). METHODS This survey conducted in January 2019 among subscribers of the International Pediatric Transplantation Association listserv aimed to explore the current strategies to prevent and manage both infections in the pediatric SOT population, including recommending LAV after SOT. RESULTS The answers given by 95 pediatric SOT healthcare workers show that these strategies are not yet optimal and call for further education. In particular, 59% of respondents are unnecessarily waiting for a SOT candidate to be >1 year of age to start administrating LAV before SOT. Interestingly, most respondents are willing to administer LAV after SOT (57%), and a fifth (21%) are already doing so, off-label. The survey queried the precautions taken to improve safety evaluations after LAV, and identified knowledge gaps and practitioners' concerns. CONCLUSION The results of this survey could be used as a starting point for education and promotion of the safe administration of LAV in carefully selected SOT recipients; in turn, this would increase available data that would contribute to the development of evidence-based guidelines by the transplant societies and ultimately prevent these infections after SOT.
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Affiliation(s)
- Laure F Pittet
- Department of Women, Children and Adolescents, Division of General Pediatrics, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Lara Danziger-Isakov
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH, USA
| | - Upton D Allen
- Division of Infectious Diseases, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Monica I Ardura
- Pediatric Infectious Diseases, Host Defense Program, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Abanti Chaudhuri
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Elizabeth Goddard
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | | | | | - Dimitri Van der Linden
- Pediatric Infectious Diseases, General Pediatrics, Pediatric Department, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Michael Green
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Klara M Posfay-Barbe
- Department of Women, Children and Adolescents, Division of General Pediatrics, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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13
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Kamei K, Miyairi I, Ishikura K, Ogura M, Shoji K, Arai K, Ito R, Kawai T, Ito S. Prospective study of live attenuated vaccines for patients receiving immunosuppressive agents. PLoS One 2020; 15:e0240217. [PMID: 33002085 PMCID: PMC7529194 DOI: 10.1371/journal.pone.0240217] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 09/21/2020] [Indexed: 11/19/2022] Open
Abstract
Patients receiving immunosuppressive agents are at risk of life-threatening infections. However, live vaccines are generally contraindicated in them. We conducted a prospective study regarding live attenuated vaccines for them. Patients elder than one year of age with immunosuppressive agents who showed negative or borderline antibody titers (virus-specific IgG levels < 4.0) against one or more of measles, rubella, varicella, and mumps and fulfilled the criteria (CD4 cell counts ≥ 500/mm3, stimulation index of lymphocyte blast transformation by PHA ≥ 101.6, serum IgG level ≥ 300 mg/dl, no steroid use or prednisolone < 1 mg/kg/day or < 2 mg/kg/2 days, trough levels of tacrolimus or cyclosporine were < 10 ng/ml or < 100 ng/ml and under good control of primary disease) were enrolled. Sixty-four vaccinations were administered to 32 patients. The seroconversion rates for measles, rubella, varicella, and mumps were 80.0%, 100.0%, 59.1%, and 69.2%, respectively. No life-threatening adverse events were observed, although one patient suffered from vaccine-strain varicella who showed cellular and humoral immunodeficiency (CD4 cell counts = 511/mm3, stimulation index of lymphocyte blast transformation by PHA = 91.1, serum IgG level = 208 mg/dl). This girl was immunized before we established the criteria for vaccination. Immunization with live attenuated vaccines for patients receiving immunosuppressive agents might be effective and safe if their cellular and humoral immunological parameters are within normal levels. However, determining the criteria for vaccination by immunological parameters should be established to guarantee the safety of live vaccines in the future. Clinical Trial Registration: UMIN Clinical Trials Registry (UMIN-CTR) UMIN000007710. The date of registration: 2012/4/13.
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Affiliation(s)
- Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
- * E-mail:
| | - Isao Miyairi
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kensuke Shoji
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Katsuhiro Arai
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Ito
- Department of General Pediatrics, National Center for Child Health and Development, Tokyo, Japan
| | - Toshinao Kawai
- Division of Immunology, National Center for Child Health and Development, Tokyo, Japan
| | - Shuichi Ito
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
- Department of Pediatrics, Yokohama City University, Kanagawa, Japan
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14
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Suresh S, Upton J, Green M, Pham-Huy A, Posfay-Barbe KM, Michaels MG, Top KA, Avitzur Y, Burton C, Chong PP, Danziger-Isakov L, Dipchand AI, Hébert D, Kumar D, Morris SK, Nalli N, Ng VL, Nicholas SK, Robinson JL, Solomon M, Tapiero B, Verma A, Walter JE, Allen UD. Live vaccines after pediatric solid organ transplant: Proceedings of a consensus meeting, 2018. Pediatr Transplant 2019; 23:e13571. [PMID: 31497926 DOI: 10.1111/petr.13571] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/12/2019] [Accepted: 07/26/2019] [Indexed: 12/11/2022]
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.
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Affiliation(s)
- Sneha Suresh
- Division of Infectious Disease and IHOPE, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Julia Upton
- Division of Immunology and Allergy, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Michael Green
- Division of Infectious Diseases, Department of Pediatrics, Pediatric Transplant Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anne Pham-Huy
- Division of Infectious Diseases, Immunology and Allergy, Department of Paediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Klara M Posfay-Barbe
- Division of Pediatric Infectious Diseases, Department of Paediatrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Marian G Michaels
- Division of Infectious Diseases, Department of Pediatrics, Pediatric Transplant Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Karina A Top
- Division of Infectious Diseases, Department of Pediatrics, Dalhousie University, Canadian Center for Vaccinology IWK Health Centre, Halifax, NS, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Catherine Burton
- Division of Infectious Diseases, Department of Paediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Pearlie P Chong
- Division of Infectious Diseases, Department of Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Lara Danziger-Isakov
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Anne I Dipchand
- Department of Paediatrics, Labatt Family Heart Centre, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Diane Hébert
- Division of Nephrology, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Deepali Kumar
- Department of Medicine, Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Shaun K Morris
- Division of Infectious Diseases, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Nadya Nalli
- Department of Pharmacy, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, ON, Canada
| | - Vicky Lee Ng
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Sarah Kogan Nicholas
- Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Joan L Robinson
- Division of Infectious Diseases and Immunology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Bruce Tapiero
- Division of Infectious Diseases, Department of Paediatrics, CHU Sainte Justine, University of Montreal, Montreal, QC, Canada
| | - Anita Verma
- Department of Infection Science, Kings College Hospital, London, UK
| | - Jolan E Walter
- Division of Pediatric Allergy/Immunology, Department of Pediatrics, University of South Florida, John's Hopkins All Children's Hospital, St. Petersburg, Florida.,Division of Pediatric Allergy/Immunology, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Upton D Allen
- Division of Infectious Diseases, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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15
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Long-term Seroprotection of Varicella-zoster Immunization in Pediatric Liver Transplant Recipients. Transplantation 2019; 103:e355-e364. [DOI: 10.1097/tp.0000000000002866] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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16
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Pergam SA, Limaye AP. Varicella zoster virus in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13622. [PMID: 31162727 DOI: 10.1111/ctr.13622] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/19/2019] [Accepted: 05/29/2019] [Indexed: 12/21/2022]
Abstract
These updated guidelines from the American Society of Transplantation Infectious Diseases Community of Practice review the diagnosis, prevention, and management of varicella zoster virus (VZV) in the pre- and post-transplant period. Primary varicella is an uncommon complication post-solid-organ transplant (SOT), except among pediatric transplant patients and those seronegative for VZV. As the majority of SOT recipients are seropositive for VZV, herpes zoster (HZ) occurs frequently following SOT, particularly among recipients who are older (≥65 years of age) and those receiving more intensive immunosuppression. Transplant providers should aware of the increased risk for HZ-related complications such as dissemination, organ-specific involvement, and post-herpetic neuralgia. Treatment for localized zoster is primarily given as oral regimens, but those with more complicated presentations or those at risk for dissemination should be treated initially with IV therapy. Available antiviral prophylaxis regimens and vaccination strategies for varicella and HZ among these immunosuppressed patients remain a mainstay for prevention in the pre-and post-transplant periods. Finally, we discuss important approaches to addressing post-exposure prophylaxis and infection control practices for those SOT patients with documented VZV infections.
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Affiliation(s)
- Steven A Pergam
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Ajit P Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
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17
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Pittet LF, Verolet CM, McLin VA, Wildhaber BE, Rodriguez M, Cherpillod P, Kaiser L, Siegrist CA, Posfay-Barbe KM. Multimodal safety assessment of measles-mumps-rubella vaccination after pediatric liver transplantation. Am J Transplant 2019; 19:844-854. [PMID: 30171797 DOI: 10.1111/ajt.15101] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/31/2018] [Accepted: 08/18/2018] [Indexed: 01/25/2023]
Abstract
Live-attenuated vaccines are currently contraindicated in solid-organ transplant recipients. However, the risk of vaccine-preventable infections is lifelong, and can be particularly severe after transplantation. In this prospective interventional national cohort study, 44 pediatric liver transplant recipients with measles IgG antibodies <150 IU/L (below seroprotection threshold) received measles-mumps-rubella vaccine (MMR) at a median of 6.3 years posttransplantation (interquartile range, 4.0 to 10.9). A maximum of two additional doses were administered in nonresponders or when seroprotection was lost. Vaccine responses occurred in 98% (95% confidence interval [CI], 88-100) of patients. Seroprotection at 1-, 2-, and 3-year follow-up reached 62% (95% CI, 45-78), 86% (95% CI, 70-95), and 89% (95% CI, 67-99), respectively. All patients responded appropriately to the booster dose(s). Vaccinations were well tolerated and no serious adverse event attributable to vaccination was identified during the 8-week follow-up period (or later), using a multimodal approach including standardized telephone interviews, diarized side effect reporting, and monitoring of vaccinal virus shedding. We conclude that live attenuated MMR vaccine can be administered in liver transplant recipients fulfilling specific eligibility criteria (>1 year posttransplantation, low immunosuppression, lymphocyte count ≥0.75 G/L), inducing seroprotection in most subjects. (Clinicaltrials.gov number NCT01770119).
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Affiliation(s)
- Laure F Pittet
- Department of Pediatrics, Division of General Pediatrics, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Charlotte M Verolet
- Department of Pediatrics, Division of General Pediatrics, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Valérie A McLin
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition Unit, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Barbara E Wildhaber
- Department of Pediatrics, University Center of Pediatric Surgery of Western Switzerland, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Maria Rodriguez
- Department of Pediatrics, Division of General Pediatrics, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Pascal Cherpillod
- Laboratory of Virology, Division of Infectious Diseases, University Hospital of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Laurent Kaiser
- Laboratory of Virology, Division of Infectious Diseases, University Hospital of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Claire-Anne Siegrist
- Department of Pediatrics, Division of General Pediatrics, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.,Centre for Vaccinology, Departments of Pathology-Immunology and Pediatrics, University of Geneva, Geneva, Switzerland
| | - Klara M Posfay-Barbe
- Department of Pediatrics, Division of General Pediatrics, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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18
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Dulek DE, de St Maurice A, Halasa NB. Vaccines in pediatric transplant recipients-Past, present, and future. Pediatr Transplant 2018; 22:e13282. [PMID: 30207024 DOI: 10.1111/petr.13282] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 07/11/2018] [Accepted: 07/12/2018] [Indexed: 12/20/2022]
Abstract
Infections significantly impact outcomes for solid organ and hematopoietic stem cell transplantation in children. Vaccine-preventable diseases contribute to morbidity and mortality in both early and late posttransplant time periods. Several infectious diseases and transplantation societies have published recommendations and guidelines that address immunization in adult and pediatric transplant recipients. In many cases, pediatric-specific studies are limited in size or quality, leading to recommendations being based on adult data or mixed adult-pediatric studies. We therefore review the current state of evidence for selected immunizations in pediatric transplant recipients and highlight areas for future investigation. Specific attention is given to studies that enrolled only children.
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Affiliation(s)
- Daniel E Dulek
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Annabelle de St Maurice
- Division of Pediatric Infectious Diseases, Department of Pediatrics, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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19
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Trivin-Avillach C, Thervet É. [Immunizations for patients with kidney disease]. Nephrol Ther 2018; 15:233-240. [PMID: 29887267 DOI: 10.1016/j.nephro.2017.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/23/2017] [Accepted: 11/19/2017] [Indexed: 12/18/2022]
Abstract
Chronic kidney disease (CKD) is associated with significant infectious complications leading to adverse health outcomes. This increased susceptibility to infection can be related to the nephropathy itself as observed in nephrotic syndrome, to the treatment especially in situations requiring immunosuppressive drugs or related to dialysis. Despite a less effective response to vaccination, some data emphasize similar benefits from immunization among people with CKD to the general population. However, some situations encountered in nephrology require adaptation of immunization practices. The aim of this review is to provide a synthesis of the existing guidelines for immunization in the field of nephrology.
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Affiliation(s)
| | - Éric Thervet
- Service de néphrologie, université Paris-Descartes, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France.
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20
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Kamei K, Miyairi I, Ishikura K, Ogura M, Shoji K, Funaki T, Ito R, Arai K, Abe J, Kawai T, Onodera M, Ito S. Prospective Study of Live Attenuated Vaccines for Patients with Nephrotic Syndrome Receiving Immunosuppressive Agents. J Pediatr 2018; 196:217-222.e1. [PMID: 29499990 DOI: 10.1016/j.jpeds.2017.12.061] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 12/04/2017] [Accepted: 12/20/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To conduct a prospective study to evaluate the immunogenicity and safety of live attenuated vaccines in patients with nephrotic syndrome receiving immunosuppressive agents. STUDY DESIGN Patients with nephrotic syndrome receiving immunosuppressive agents with negative or borderline antibody titers (virus-specific IgG levels <4.0) against measles, rubella, varicella, and/or mumps fulfilling the criteria of cellular and humoral immunity were enrolled. Virus-specific IgG levels were measured using an enzyme immunoassay. The primary endpoint was the seroconversion rate (ie, achievement of virus-specific IgG levels ≥4.0) at 2 months after vaccination. Virus-specific IgG levels at 1 year, breakthrough infections (wild-type infections), and adverse events were also evaluated. RESULTS A total of 116 vaccinations were administered to 60 patients. Seroconversion rates were 95.7% for measles, 100% for rubella, 61.9% for varicella, and 40.0% for mumps. More patients with a borderline antibody titer before vaccination achieved seroconversion than those with negative antibody titer, with statistical significance after varicella and mumps vaccination. The rate of patients who maintained seropositivity at 1 year after vaccination was 83.3% for measles, 94.1% for rubella, 76.7% for varicella, and 20.0% for mumps. No patient experienced breakthrough infection. No serious adverse events, including vaccine-associated infection, were observed. CONCLUSION Immunization with live attenuated vaccines may be immunogenic and is apparently safe in our cohort of patients with nephrotic syndrome receiving immunosuppressive agents if their cellular and humoral immunologic measures are within clinically acceptable levels. TRIAL REGISTRATION UMIN-CTR UMIN 000007710.
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Affiliation(s)
- Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan.
| | - Isao Miyairi
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kensuke Shoji
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Takanori Funaki
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Ito
- Department of General Pediatrics, National Center for Child Health and Development, Tokyo, Japan
| | - Katsuhiro Arai
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Jun Abe
- Department of Allergy and Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Toshinao Kawai
- Department of Human Genetics, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Masafumi Onodera
- Department of Human Genetics, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University, Yokohama, Japan
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21
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Vaccination titres pre- and post-transplant in paediatric renal transplant recipients and the impact of immunosuppressive therapy. Pediatr Nephrol 2018; 33:897-910. [PMID: 29322328 DOI: 10.1007/s00467-017-3868-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/29/2017] [Accepted: 12/04/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Avoidance of vaccine-preventable infections in paediatric renal allograft recipients is of utmost importance. However, the development and maintenance of protective vaccination titres may be impaired in this patient population owing to their need for immunosuppressive medication. METHODS In the framework of the Cooperative European Paediatric Renal Transplant Initiative (CERTAIN), we therefore performed a multi-centre, multi-national study and analysed vaccination titres pre- and post-transplant in 155 patients with serial titre measurements in comparison with published data in healthy children. RESULTS The percentage of patients with positive vaccination titres before renal transplantation (RTx) was low, especially for diphtheria (38.5%, control 75%) and pertussis (21.3%, control 96.3%). As few as 58.1% of patients had a hepatitis B antibody (HBsAb) titre >100 IU/L before RTx. 38.1% of patients showed a vaccination titre loss post-transplant. Patients with an HBsAb titre between 10 and 100 IU/L before RTx experienced a significantly (p < 0.05) more frequent hepatitis B vaccination titre loss post-transplant than patients with an HBsAb titre >100 IU/L. The revaccination rate post-transplant was low and revaccination failed to induce positive titres in a considerable number of patients (27.3 to 83.3%). Treatment with rituximab was associated with a significantly increased risk of a vaccination titre loss post-transplant (odds ratio 4.26, p = 0.033). CONCLUSIONS These data show a low percentage of patients with positive vaccination titres pre-transplant, a low revaccination rate post-transplant with limited antibody response, and a high rate of vaccination titre losses.
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Speth F, Hinze CH, Andel S, Mertens T, Haas JP. Varicella-zoster-virus vaccination in immunosuppressed children with rheumatic diseases using a pre-vaccination check list. Pediatr Rheumatol Online J 2018; 16:15. [PMID: 29499726 PMCID: PMC5833060 DOI: 10.1186/s12969-018-0231-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 02/20/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The goal of this study was to apply the varicella zoster virus (VZV) vaccine to patients with pediatric rheumatic diseases (PRD) at risk for severe chickenpox, without interrupting their current immunosuppression, including biological agents, using an immunological-based pre-vaccination checklist to assure safety. A pre-vaccination checklist was implemented to ensure adequate immune competence prior to immunization. METHODS This prospective study included seronegative patients (VZV-IgG ≤200 mIU/ml) and patients who had previously received only a single dose of VZV vaccine. All vaccinees demonstrated clinically inactive PRD. Patients were categorized according to their actual treatment in low-intensity IS (LIIS) and high-intensity IS (HIIS) including biological therapy. The pre-vaccination checklist defined thresholds for the following basic laboratory tests: white blood cell count ≥3000/mm3, lymphocytes ≥1200/mm3, serum IgG ≥500 mg/dl, IgM ≥20 mg/dl, tetanus toxoid antibody ≥0.1 IU/ml. In case of HIIS additional specifications included a CD4+ lymphocyte count ≥200/mm3 and a positive T-cell function (via analyzable positive control of a standard tuberculosis interferon-gamma-release-assay (TB-IGRA) indicating mitogen-induced T cell proliferation). Patients who met the criteria of the pre-vaccination checklist received the first and/or second VZV vaccination. Immunologic response and side effects were monitored. RESULTS Twenty-three patients were recruited of whom nine had already received one VZV immunization before initiating IS. All patients met the pre-vaccination checklist criteria despite ongoing IS. There was no overall difference in VZV-IgG levels when comparing the LIIS (n=9) and HIIS (n=14) groups. In total, 21 patients (91%) showed a positive vaccination response, after the first immunization the median VZV-IgG across all patients was 224 (59-1219) mIU/ml (median (range)), after booster immunization it increased to 882 (30-4685) mIU/ml. Two patients in the HIIS group failed to raise positive VZV-IgG, despite booster immunization. All nine patients receiving only the second immunization on IS reached high titers of VZV-IgG >500 mIU/ml (1117 (513-4685) mIU/ml). There were no cases of rash or other vaccine-induced varicella disease symptoms and no evidence of PRD flare. CONCLUSIONS VZV vaccination is safe and largely immunogenic in children with ongoing IS fulfilling an immunological based pre-vaccination checklist. This new approach is based on immunologic function rather than on type of medications. TRIAL REGISTRATION NUMBER ISRCRTN trial registration number 21654693 , date of registration February 12, 2018, retrospectively registered.
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Affiliation(s)
- Fabian Speth
- German Center for Pediatric and Adolescent Rheumatology, Gehfeldstr. 24, 82467 Garmisch-Partenkirchen, Germany
| | - Claas H. Hinze
- 0000 0004 0551 4246grid.16149.3bDepartment of Pediatric Rheumatology and Immunology, University Hospital Münster, Albert-Schweitzer-Campus I, Building W30, 48149 Münster, Germany
| | - Susanne Andel
- German Center for Pediatric and Adolescent Rheumatology, Gehfeldstr. 24, 82467 Garmisch-Partenkirchen, Germany
| | - Thomas Mertens
- grid.410712.1Institute of Virology, Ulm University Medical Center, Albert-Einstein-Allee 11, 89081 Ulm, Germany
| | - Johannes-Peter Haas
- German Center for Pediatric and Adolescent Rheumatology, Gehfeldstr. 24, 82467 Garmisch-Partenkirchen, Germany
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24
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Croce E, Hatz C, Jonker EF, Visser L, Jaeger VK, Bühler S. Safety of live vaccinations on immunosuppressive therapy in patients with immune-mediated inflammatory diseases, solid organ transplantation or after bone-marrow transplantation – A systematic review of randomized trials, observational studies and case reports. Vaccine 2017; 35:1216-1226. [DOI: 10.1016/j.vaccine.2017.01.048] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/10/2017] [Accepted: 01/20/2017] [Indexed: 11/29/2022]
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25
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Humoral and cellular response after varicella vaccination in VZV IgG seronegative kidney transplant candidates. Vaccine 2017; 35:71-76. [DOI: 10.1016/j.vaccine.2016.11.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 11/04/2016] [Accepted: 11/12/2016] [Indexed: 11/22/2022]
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26
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L'Huillier AG, Kumar D. Immunizations in solid organ and hematopoeitic stem cell transplant patients: A comprehensive review. Hum Vaccin Immunother 2016; 11:2852-63. [PMID: 26291740 DOI: 10.1080/21645515.2015.1078043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The Solid Organ Transplantation (SOT) and Haematopoietic Stem Cell Transplantation (HSCT) population is continuously increasing as a result of broader indications for transplant and improved survival. Infectious diseases, including vaccine-preventable diseases, are a significant threat for this population, primarily after but also prior to transplantation. As a consequence, clinicians must ensure that patients are optimally immunized before transplantation, to provide the best protection during the early post-transplantation period, when immunosuppression is the strongest and vaccine responses are poor. After 3-6 months, inactivated vaccines immunization can be resumed. By contrast, live-attenuated vaccines are lifelong contraindicated in SOT patients, but can be considered in HSCT patients at least 2 years after transplantation, if there is no immunosuppression or graft-versus-host-disease. However, because of the advantages of live-attenuated over inactivated vaccines--and also sometimes the absence of an inactivated alternative--an increasing number of prospective studies on live vaccine immunization after transplantation are performed and give new insights about safety and immunogenicity in this population.
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Affiliation(s)
- Arnaud G L'Huillier
- a Pediatric Infectious Diseases Unit, Department of Pediatrics; University Hospitals of Geneva & Geneva Medical School , Geneva , Switzerland
| | - Deepali Kumar
- b Transplant Infectious Diseases and Multi-Organ Transplant Program; University Health Network ; Toronto , Ontario , Canada
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Demir Z, Frange P, Lacaille F. Vaccinations, response, and controls before and after intestinal transplantation in children. Pediatr Transplant 2016; 20:449-55. [PMID: 26847771 DOI: 10.1111/petr.12669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2015] [Indexed: 11/25/2022]
Abstract
Vaccination is an effective strategy to decrease infections in transplant recipients. Children after intestinal transplantation carry a high risk of infection due to increased immunosuppression. In a series of 22 children after intestinal transplantation, we studied the vaccination schedules and the antibodies against vaccine-preventable diseases before transplantation, and at one and five yr after transplantation. We reviewed whether the vaccination schedules were complete, and we analysed the factors that may influence serological immunity and the incidence of disease in patients with deficient immunity. All patients completed the recommended vaccination schedules for DTaP-IPV and HBV. After transplantation, the negative antibodies against vaccine-preventable diseases were mostly related to an antirejection therapy: for DTaP-IPV: four of four patients with no antibody had been treated for rejection, for HBV: two of five, HAV: three of four, MMR: three of seven, and VZV: three of four. A post-transplantation varicella infection was followed by acute rejection, with probability for a relationship between both events. We observed 50% of varicella cases in unvaccinated children, highlighting the importance of pretransplant vaccination. Waning immunogenicity mediated by antibodies against vaccine-preventable disease after transplantation indicated a need for boosters. The recommendations should be regularly enforced, as the reliance on routine immunizations schedules is not adequate in immunocompromised patients.
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Affiliation(s)
- Z Demir
- Pediatric Hepato-Gastro-Enterology-Nutrition Unit, Necker-Enfants Malades Hospital, Paris, France
| | - P Frange
- Microbiology Department, Necker-Enfants Malades Hospital, Paris, France.,Pediatric Immunology and Hematology Unit, Necker Hospital, Paris, France.,EA 7327, Paris Descartes University, Sorbonne Paris Cite, Paris, France
| | - F Lacaille
- Pediatric Hepato-Gastro-Enterology-Nutrition Unit, Necker-Enfants Malades Hospital, Paris, France
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Immunization practices in solid organ transplant recipients. Vaccine 2016; 34:1958-64. [DOI: 10.1016/j.vaccine.2016.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 12/25/2015] [Accepted: 01/14/2016] [Indexed: 01/26/2023]
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Vaccine administration in children with chronic kidney disease. Vaccine 2015; 32:6601-6. [PMID: 25275950 DOI: 10.1016/j.vaccine.2014.09.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 06/23/2014] [Accepted: 09/19/2014] [Indexed: 01/29/2023]
Abstract
Pediatric patients with severe chronic kidney disease (CKD) on conservative treatment, on dialysis, and those with renal transplantation are at a higher risk for infectious diseases as the result of impaired immune responses against infectious agents. Infections in these patients can have drastic consequences for disease morbidity and mortality. Immunization is a crucial preventive strategy for disease management in this pediatric population. However, vaccination coverage among children with CKD remains low due to safety concerns and doubts about vaccine immunogenicity and efficacy. In this study, we reviewed why children with CKD are at higher risk of infections, the importance of vaccinations among these children, barriers to vaccinations, and recommend the best vaccination schedules. Overall, vaccines have acceptable immunogenicity, efficacy, and safety profiles in children with CKD. However, in some cases, the protective antibody levels induced by vaccines and the benefits and risks of booster vaccine doses must be individually managed. Furthermore, close contacts and household members of these children should complete age-appropriate vaccination schedules to increase the child's indirect protection.
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Abstract
Solid organ and hematopoietic stem cell transplant recipients may be exposed to diseases which may be prevented through live attenuated virus vaccines (LAVV). Because of their immunosuppression, these diseases can lead to severe complications in transplant recipients. Despite increasing evidence regarding the safety and effectiveness of certain LAVV, these vaccines are still contraindicated for immunocompromised patients, such as transplant recipients. We review the available studies on LAVV, such as varicella zoster, measles-mumps-rubella, influenza, yellow fever, polio, and Japanese encephalitis vaccines in transplant patients. We discuss the current recommendations and the potential risks, as well as the expected benefits of LAVV immunization in this population.
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Affiliation(s)
- Charlotte M Verolet
- Pediatric Infectious Diseases Unit, Division of General Pediatrics, Department of Pediatrics, University Hospitals of Geneva & University of Geneva Medical School, Geneva, Switzerland,
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Low LL, Vasanwala FF, Suhail SM. Varicella encephalitis and pneumonia in a patient with end stage renal failure. ASIA PACIFIC FAMILY MEDICINE 2014; 13:4. [PMID: 24555522 PMCID: PMC3974108 DOI: 10.1186/1447-056x-13-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 02/17/2014] [Indexed: 05/15/2023]
Abstract
We describe a patient with end stage renal failure (ESRF) on hemodialysis who was admitted to our department for primary varicella infection complicated by varicella pneumonia and encephalitis. Varicella infections results in serious morbidity and mortality in ESRF dialysis and transplant patients. Evidence published thus far suggests that live attenuated varicella vaccines are effective and safe in ESRF and renal transplant patients. Worldwide a few countries have instituted guidelines for the varicella immunisation in ESRF patients. However, in the Asia Pacific Region, it has not been widely given due to the lack of national consensus guidelines. Our case depicts that primary varicella infection can occur at any time in immunosupressed patients and thus suffer serious consequences from it. With increasing burden of chronic kidney disease, Renal Physicians and Family Physicians in the Asia Pacific Region should meet and study the epidemiological data in each individual country and decide on the consensus guidelines on how the varicella vaccination can be targeted for those at risk.
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Affiliation(s)
- Lian Leng Low
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Bowyer Block A, Level 2, 169608 Outram Road, Singapore
| | - Farhad Fakhrudin Vasanwala
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Bowyer Block A, Level 2, 169608 Outram Road, Singapore
| | - Sufi Muhammad Suhail
- Department of Renal medicine, Singapore General Hospital, Outram Road, Singapore
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Abstract
ABSTRACT: Live-attenuated viral vaccines (LAV) have been used safely for several decades in healthy individuals to protect against diseases with great success. In immunocompromised hosts their use is usually not recommended. We explore the use of currently available LAV, such as live-attenuated influenza, varicella–zoster virus, measles, mumps and rubella, oral polio, rotavirus, yellow fever virus vaccines, especially in patients with cancer, solid organ or hematopoietic stem cell transplant, HIV, and with acquired or congenital immunodeficiencies. Although evidence-based recommendations cannot currently be made, it is possible that LAV will be recommended in specific, well-defined situations in these immunocompromised patients in the future.
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Affiliation(s)
- Arnaud G L’Huillier
- Pediatric Infectious Diseases Unit, Division of General Pediatrics, Department of Pediatrics, University Hospitals of Geneva & University of Geneva Medical School, Geneva, Switzerland
| | - Klara M Posfay-Barbe
- Pediatric Infectious Diseases Unit, Division of General Pediatrics, Department of Pediatrics, University Hospitals of Geneva & University of Geneva Medical School, Geneva, Switzerland
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Prelog M, Schönlaub J, Jeller V, Almanzar G, Höfner K, Gruber S, Eiwegger T, Würzner R. Reduced varicella-zoster-virus (VZV)-specific lymphocytes and IgG antibody avidity in solid organ transplant recipients. Vaccine 2013; 31:2420-6. [PMID: 23583889 DOI: 10.1016/j.vaccine.2013.03.058] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/04/2013] [Accepted: 03/28/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Varicella-zoster-virus (VZV) infection may cause significant morbidity and mortality in immunocompromised patients. So far, only IgG-anti-VZV antibody concentrations were used to estimate immunity against VZV, but the antibody binding strength (avidity) together with VZV-specific cellular responses have not been evaluated in solid organ transplant (SOT) recipients. METHODS Thus, we assessed the humoral and cellular immune responses to two doses of the VZV vaccine (vacc) and wild-type VZV infection (wt) in 23 kidney (KTx) and 19 liver transplant (LTx) recipients including children and adults compared to 48 healthy controls (HC) for measurement of IgG-anti-VZV relative avidity index (RAI) and frequency of VZV-specific peripheral blood mononuclear cells (PBMCs) in vaccinated individuals using an adapted ELISA and IFN-gamma ELISPOT, respectively. RESULTS KTx(wt) (median RAI 72.3%) or LTx(wt) (79.2%) and KTx(vacc) (91.0%) or LTx(vacc) (72.5%) showed lower avidities compared to HC(wt) (84.5%) and HC(vacc) (94.0%), respectively, despite equally distributed IgG-anti-VZV concentrations. RAI>60% (high avidity) was detected in all HC, but only in 69.0% of SOT patients. KTx(vacc) (median 64 spot forming units SFU/500,000 PBMCs) and LTx(vacc) (67 SFU) had significantly lower VZV-specific cellular responses compared to HC(vacc) (268 SFU). CONCLUSIONS The diminished cellular reactivity to VZV has to be considered in SOT patients receiving immunosuppressive treatments when evaluating immunity against VZV. IgG antibody avidity and VZV-specific cellular responses may serve as additional markers to evaluate immunity against VZV in SOT recipients. The role of wild-type exposures and endogenous VZV re-activation on long-term immunity in SOT patients has to be awaited to establish recommendations for vaccine spacing in these patients, considering immunogenicity and safety aspects.
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Affiliation(s)
- Martina Prelog
- Department of Pediatrics, Innsbruck Medical University, Innsbruck, Austria.
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Pergam SA, Limaye AP. Varicella zoster virus in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:138-46. [PMID: 23465007 PMCID: PMC5331930 DOI: 10.1111/ajt.12107] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Steven A. Pergam
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ajit P. Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
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Eckerle I, Rosenberger KD, Zwahlen M, Junghanss T. Serologic vaccination response after solid organ transplantation: a systematic review. PLoS One 2013; 8:e56974. [PMID: 23451126 PMCID: PMC3579937 DOI: 10.1371/journal.pone.0056974] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 01/16/2013] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Infectious diseases after solid organ transplantation (SOT) are one of the major complications in transplantation medicine. Vaccination-based prevention is desirable, but data on the response to active vaccination after SOT are conflicting. METHODS In this systematic review, we identify the serologic response rate of SOT recipients to post-transplantation vaccination against tetanus, diphtheria, polio, hepatitis A and B, influenza, Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitides, tick-borne encephalitis, rabies, varicella, mumps, measles, and rubella. RESULTS Of the 2478 papers initially identified, 72 were included in the final review. The most important findings are that (1) most clinical trials conducted and published over more than 30 years have all been small and highly heterogeneous regarding trial design, patient cohorts selected, patient inclusion criteria, dosing and vaccination schemes, follow up periods and outcomes assessed, (2) the individual vaccines investigated have been studied predominately only in one group of SOT recipients, i.e. tetanus, diphtheria and polio in RTX recipients, hepatitis A exclusively in adult LTX recipients and mumps, measles and rubella in paediatric LTX recipients, (3) SOT recipients mount an immune response which is for most vaccines lower than in healthy controls. The degree to which this response is impaired varies with the type of vaccine, age and organ transplanted and (4) for some vaccines antibodies decline rapidly. CONCLUSION Vaccine-based prevention of infectious diseases is far from satisfactory in SOT recipients. Despite the large number of vaccination studies preformed over the past decades, knowledge on vaccination response is still limited. Even though the protection, which can be achieved in SOT recipients through vaccination, appears encouraging on the basis of available data, current vaccination guidelines and recommendations for post-SOT recipients remain poorly supported by evidence. There is an urgent need to conduct appropriately powered vaccination trials in well-defined SOT recipient cohorts.
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Affiliation(s)
- Isabella Eckerle
- Section of Clinical Tropical Medicine, Department of Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany.
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36
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Vaccination of immunocompromised hosts. Vaccines (Basel) 2013. [DOI: 10.1016/b978-1-4557-0090-5.00016-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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37
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L'Huillier AG, Wildhaber BE, Belli DC, Diana A, Rodriguez M, Siegrist CA, Posfay-Barbe KM. Successful serology-based intervention to increase protection against vaccine-preventable diseases in liver-transplanted children: a 19-yr review of the Swiss national reference center. Pediatr Transplant 2012; 16:50-7. [PMID: 22093802 DOI: 10.1111/j.1399-3046.2011.01600.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
As children referred for OLT in Switzerland were not vaccinated optimally, new guidelines were developed and recommended to base catch-up immunization on serum antibody titers against vaccine-preventable diseases, before and after OLT. We measure the results of this serology-based intervention by comparing vaccine coverage and antibody titers in the pre- (1990-2002, P1) and post-intervention (2003-2008, P2) cohorts in a quality control project. Forty-four P1 and 30 P2 children were evaluated. At pre-OLT visit, D, T, SPn, and MMR serologies were checked more frequently in P2 than P1 (p < 0.05). More P2 children were up-to-date for DTaP and MMR (p < 0.05) or had received ≥1 dose of HBV, HAV, SPn, and VZV vaccines (p < 0.05). One yr post-OLT, DT, SPn, MMR, and VZV serologies were more frequently checked (p < 0.05), and antibody titers were higher for DT and HAV (p < 0.05) in P2. Gender, age, or diagnosis did not explain these differences. Among P2 patients, pre- and post-OLT titers for D, T, Hib, HBV, SPn14, and SPn19 were correlated (p < 0.05 for all). Protection against vaccine-preventable diseases of high-risk children like OLT patients can be significantly improved by serology-based intervention for vaccine-preventable diseases.
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Affiliation(s)
- A G L'Huillier
- Department of Pediatrics, University Hospitals of Geneva, Switzerland
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Abuali MM, Arnon R, Posada R. An update on immunizations before and after transplantation in the pediatric solid organ transplant recipient. Pediatr Transplant 2011; 15:770-7. [PMID: 22111996 DOI: 10.1111/j.1399-3046.2011.01593.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Vaccination offers a unique opportunity to decrease the burden of infectious complications following solid organ transplantation. In this paper we review the current guidelines for routine immunizations before and after solid organ transplantation, including the recent updates and changes to recommendations for certain vaccines. We also address the issue of waning immunity in solid organ transplant recipients and discuss the current data on vaccinating this patient population with live vaccines after transplantation.
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Affiliation(s)
- Mayssa M Abuali
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY 10029, USA
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Kamei K, Miyazono A, Sato M, Ishikawa T, Fujimaru T, Ogura M, Ito S. Efficacy and safety of attenuated live vaccines in children with renal disease receiving immunosuppressants. ACTA ACUST UNITED AC 2011. [DOI: 10.3165/jjpn.24.179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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40
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Varicella vaccination in children with inflammatory bowel disease receiving immunosuppressive therapy. J Pediatr Gastroenterol Nutr 2010; 50:562-5. [PMID: 20639716 PMCID: PMC3955715 DOI: 10.1097/mpg.0b013e3181bab351] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Children with inflammatory bowel disease (IBD) are often receiving chronic immunosuppressive therapy to stay in clinical remission; however, these therapies also put patients at risk for infections. Therefore, it is important to immunize children to minimize vaccine-preventable infections. However, there is a paucity of data on immune response to vaccines in patients with IBD. Current guidelines recommend that patients with IBD receive inactivated vaccines but suggest against immunizing immunosuppressed patients having IBD with live vaccines such as varicella. Unfortunately, the recommendation to not vaccinate with varicella was not based on any data. We present a case series of children with IBD receiving immunosuppressive therapy who tolerated and had a good immune response to varicella vaccine. We also review the literature and demonstrate that studies in other immunocompromised populations suggest that varicella vaccine is generally well tolerated and immunogenic. We also argue that it is important to weigh the benefits against risks with individual patients having IBD to decide whether varicella vaccination should be considered. Additional studies evaluating the safety and immunogenicity of varicella vaccine in patients with IBD are needed.
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Immunization in Renal Transplant Recipients: Where Do We Stand? Int J Organ Transplant Med 2010. [DOI: 10.1016/s1561-5413(10)60003-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Reports about efficacy and safety of live-virus attenuated vaccines in patients before and after transplantation are mainly based on small patient numbers, making general recommendations for this patient population difficult. Children and adults as well as their close relatives and contact persons should be preferably immune to VZV before solid organ transplantation to avoid VZV-associated complications, thus making VZV vaccination necessary in susceptible individuals. The following literature review focused on efficacy and safety of VZV vaccination in pediatric kidney and liver transplant recipients. Review of literature also revealed that in all pediatric transplant candidates, humoral and cellular immunity against VZV should be consistently monitored to assess waning immunity under immunosuppressive treatment. This approach is desirable to estimate the risk of severe varicella disease after exposure in these patients.
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Affiliation(s)
- Martina Prelog
- Department of Pediatrics, Pediatrics I, Medical University Innsbruck, Anichstr. 35, A-6020 Innsbruck, Austria.
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Barton M, Wasfy S, Melbourne T, Hébert D, Moore D, Robinson J, Marchese RD, Allen UD. Sustainability of humoral responses to varicella vaccine in pediatric transplant recipients following a pretransplantation immunization strategy. Pediatr Transplant 2009; 13:1007-13. [PMID: 19207222 DOI: 10.1111/j.1399-3046.2008.01113.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Varicella infections pose serious challenges for organ transplant recipients. To determine the safety and immunogenicity of the OMVV and determine the maintenance of OMVV responses in transplanted subjects at varying periods of immunosuppression within the first two yr following transplantation. Eligible subjects given a two-dose OMVV pretransplantation were monitored for AE. Antibody levels were assessed at baseline, six wk post-OMVV, pretransplantation and up to 24 months post-transplantation. Seroprotection was defined as >or=5 gpEU. Twenty-one seronegative children were vaccinated. Following 42 doses, no vaccine-related serious AE occurred. Mab_titer were 17.8 (5.7-910.2) and 183.5 EU (18.8-8116.4) at six and 12 wk, respectively (p < 0.0001). Fourteen (66.7%) participants were transplanted at a median of 16 months (1.5-56) following OMVV and had Mab_titer of 27.2 EU (9.0-236.2) just prior to transplantation. Of 11 who had post-transplantation serology, seroprotection was sustained at three, six and 12 months post-transplantation in 10/11, 12/12 and 8/10 subjects. In five of six subjects with two-yr follow-up, antibody levels remained seroprotective. No breakthrough varicella infections occurred. The receipt of OMVV prior to transplantation induced humoral responses which persisted in the early months following transplantation and up to two yr post-transplantation and was not associated with any serious adverse consequences.
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Affiliation(s)
- Michelle Barton
- Department of Pediatrics, Division of Infectious Diseases, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Abstract
PURPOSE OF REVIEW Numerous recent advances have been made in the field of infectious diseases and pediatric solid organ transplant. RECENT FINDINGS Although many studies contain somewhat small cohorts of individuals, when summarized together they contribute significantly to our knowledge about pediatric solid organ transplant, especially regarding risk factors for infection, management of BK virus nephropathy, the use of live viral vaccines, and consideration for rare infections as well as donor-derived infections. SUMMARY In sum, these recent advances in infection in the field of pediatric solid organ transplant will help decrease infection, thus improving morbidity and mortality, as well as transplant outcomes, especially by decreasing direct (graft injury) and indirect (immune upregulation) effects on organ transplantation. This review will focus on recent advances in the field of infectious diseases in pediatric solid organ transplant by highlighting some of the most important and interesting articles in the field within the past few years.
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Cohn J, Blumberg EA. Immunizations for renal transplant candidates and recipients. ACTA ACUST UNITED AC 2008; 5:46-53. [DOI: 10.1038/ncpneph1003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Accepted: 10/01/2008] [Indexed: 02/01/2023]
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Danerseau AM, Robinson JL. Efficacy and safety of measles, mumps, rubella and varicella live viral vaccines in transplant recipients receiving immunosuppressive drugs. World J Pediatr 2008; 4:254-8. [PMID: 19104888 DOI: 10.1007/s12519-008-0047-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Accepted: 09/25/2008] [Indexed: 11/29/2022]
Abstract
BACKGROUND This review was designed to summarize published data on the efficacy and safety of live viral vaccines for measles, mumps, rubella, or varicella in post-transplant patients currently on immunosuppression. DATA SOURCES Medline, EMBASE and Evidence Based Medicine Reviews were searched from 1966 to November 2007 for case reports or studies describing the efficacy and/or safety of live attenuated measles, mumps, rubella, or varicella vaccine in children on immunosuppression following solid organ, bone marrow or stem cell transplantation. RESULTS The review identified 6 case series and 2 case reports describing 114 solid organ transplant recipients and one case series describing 27 bone marrow transplant recipients who had received a combined total of 206 doses of live varicella, measles, mumps, or rubella vaccine while on immunosuppression. Post-immunization titers were in the immune range in 109 of the 171 situations where they were measured following a single dose of vaccine (64%) and in 15 of 22 situations following 2 doses (68%). There were no major safety concerns in this small sample. CONCLUSION There are insufficient published data to derive evidence-based guidelines for use of live viral vaccines in transplant recipients on immunosuppression but preliminary data on efficacy and safety suggest that the use of these live viral vaccines in transplant recipients still on immunosuppression could be a reasonable strategy.
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Affiliation(s)
- Angela Marie Danerseau
- Department of Pediatrics and Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
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47
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Ljungman P. Vaccination in the immunocompromised host. Vaccines (Basel) 2008. [DOI: 10.1016/b978-1-4160-3611-1.50067-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Jean-Philippe P, Freedman A, Chang MW, Steinberg SP, Gershon AA, LaRussa PS, Borkowsky W. Severe varicella caused by varicella-vaccine strain in a child with significant T-cell dysfunction. Pediatrics 2007; 120:e1345-9. [PMID: 17974726 DOI: 10.1542/peds.2004-1681] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In March 1995, the US Food and Drug Administration approved a live attenuated varicella vaccine for use in healthy children 12 months to 12 years old. We report here an 18-month-old girl with cell-mediated immunodeficiency who developed a severe vaccine-associated rash and clinical evidence of vaccine-associated pneumonia 1 month after inadvertent receipt of varicella vaccine.
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Affiliation(s)
- Patrick Jean-Philippe
- Department of Pediatrics, New York University School of Medicine, New York, New York, USA.
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49
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Abstract
Solid-organ transplant recipients are at risk from various infectious diseases, many of which can be prevented by immunizations that could reduce morbidity and mortality. However, it is not uncommon for children requiring transplantation to have received inadequate or no immunizations pre-transplant. Every effort should be made to immunize transplant candidates early in the course of their disease according to recommended schedules prior to transplantation. It is also important to immunize their household contacts and healthcare workers. In this review, we summarize the major immunization issues for children undergoing transplantation, the data currently available on immunization safety and efficacy, and suggest immunization practices to reduce vaccine-preventable disease. There is a real need for a standardized approach to the administration and evaluation of immunizations in this group of patients.
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Affiliation(s)
- Anita Verma
- Health Protection Agency, London, Region Laboratory, Department of Medical Microbiology, King's College Hospital, London, UK.
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50
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Abstract
Infections are a major cause of death in end-stage renal disease (ESRD) patients, second only to cardiovascular disease, and also contribute to significant morbidity in patients with earlier stages of chronic kidney disease (CKD). Vaccines are a strategy to attempt to reduce morbidity related to infections. Patients with CKD and ESRD may not respond as well to vaccines as patients without kidney failure, but adequate seroresponse with standard or augmented regimens for vaccinations against influenza, hepatitis B, pneumococcus, and varicella have been documented. Influenza, in particular, seems to provide adequate protection with standard dosing regimens. Despite somewhat reduced effectiveness of certain vaccines in patients with CKD, there is emerging evidence of benefit to vaccination in these populations. However, vaccination rates are relatively low. Given the accumulating evidence of benefit, continuing quality improvement programs focused on increasing vaccination rates in patients with all levels of CKD are needed.
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Affiliation(s)
- Annamaria T Kausz
- Division of Nephrology, Tufts-New England Medical Center, Boston, MA 02111, USA.
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