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Serra López-Matencio JM, Vicente-Rabaneda EF, Alañón E, Aranguren Oyarzabal A, Martínez Fleta P, Castañeda S. COVID-19 Vaccination and Immunosuppressive Therapy in Immune-Mediated Inflammatory Diseases. Vaccines (Basel) 2023; 11:1813. [PMID: 38140217 PMCID: PMC10747214 DOI: 10.3390/vaccines11121813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/25/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
The COVID-19 vaccination program has probably been the most complex and extensive project in history until now, which has been a challenge for all the people involved in the planning and management of this program. Patients with immune-mediated inflammatory diseases (IMIDs) on immunosuppressive therapy have required special attention, not only because of the particular haste in carrying out the process but also because of the uncertainty regarding their response to the vaccines. We now have strong scientific evidence that supports the hypothesis that immunosuppressive therapy inhibits the humoral response to vaccines against other infectious agents, such as influenza, pneumococcus and hepatitis B. This has led to the hypothesis that the same could happen with the COVID-19 vaccine. Several studies have therefore already been carried out in this area, suggesting that temporarily discontinuing the administration of methotrexate for 2 weeks post-vaccination could improve the vaccine response, and other studies with various immunosuppressive drugs are in the same line. However, the fact of withholding or interrupting immunosuppressive therapy when dealing with COVID-19 vaccination remains unclear. On this basis, our article tries to compile the information available on the effect of immunosuppressant agents on COVID-19 vaccine responses in patients with IMIDs and proposes an algorithm for the management of these patients.
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Affiliation(s)
- José M. Serra López-Matencio
- Hospital Pharmacy Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (E.A.); (A.A.O.)
| | | | - Estefanía Alañón
- Hospital Pharmacy Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (E.A.); (A.A.O.)
| | - Ainhoa Aranguren Oyarzabal
- Hospital Pharmacy Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (E.A.); (A.A.O.)
| | - Pedro Martínez Fleta
- Immunology Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain;
| | - Santos Castañeda
- Rheumatology Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain;
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2
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Banjongjit A, Phirom S, Phannajit J, Jantarabenjakul W, Paitoonpong L, Kittanamongkolchai W, Wattanatorn S, Prasithsirikul W, Eiam-Ong S, Avihingsanon Y, Hansasuta P, Vanichanan J, Townamchai N. Benefits of Switching Mycophenolic Acid to Sirolimus on Serological Response after a SARS-CoV-2 Booster Dose among Kidney Transplant Recipients: A Pilot Study. Vaccines (Basel) 2022; 10:vaccines10101685. [PMID: 36298550 PMCID: PMC9609831 DOI: 10.3390/vaccines10101685] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/28/2022] [Accepted: 10/06/2022] [Indexed: 11/08/2022] Open
Abstract
Kidney transplant recipients (KTRs) have a suboptimal immune response to COVID-19 vaccination due to the effects of immunosuppression, mostly mycophenolic acid (MPA). This study investigated the benefits of switching from the standard immunosuppressive regimen (tacrolimus (TAC), MPA, and prednisolone) to a regimen of mammalian target of rapamycin inhibitor (mTORi), TAC and prednisolone two weeks pre- and two weeks post-BNT162b2 booster vaccination. A single-center, opened-label pilot study was conducted in KTRs, who received two doses of ChAdOx-1 and a single dose of BNT162b2. The participants were randomly assigned to continue the standard regimen (control group, n = 14) or switched to a sirolimus (an mTORi), TAC, and prednisolone (switching group, n = 14) regimen two weeks before and two weeks after receiving a booster dose of BNT162b2. The anti-SARS-CoV-2 S antibody level after vaccination in the switching group was significantly greater than the control group (4051.0 [IQR 3142.0-6466.0] BAU/mL vs. 2081.0 [IQR 1077.0-3960.0] BAU/mL, respectively; p = 0.01). One participant who was initially seronegative in the control group remained seronegative after the booster dose. These findings suggest humoral immune response benefits of switching the standard immunosuppressive regimen to the regimen of mTORi, TAC, and prednisolone in KTRs during vaccination.
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Affiliation(s)
- Athiphat Banjongjit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Supitchaya Phirom
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Jeerath Phannajit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
- Division of Clinical Epidemiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Watsamon Jantarabenjakul
- Thai Red Cross Emerging Infectious Diseases Clinical Center, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Leilani Paitoonpong
- Thai Red Cross Emerging Infectious Diseases Clinical Center, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Wonngarm Kittanamongkolchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
- Mahachakri Sirindhorn Clinical Research Center, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Renal Immunology and Renal Transplant Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Salin Wattanatorn
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | | | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Yingyos Avihingsanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
- Renal Immunology and Renal Transplant Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Pokrath Hansasuta
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Jakapat Vanichanan
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Natavudh Townamchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
- Renal Immunology and Renal Transplant Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
- Correspondence:
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3
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Gomes ABAGR, Feo LB, Silva GD, Disserol CCD, Paolilo RB, Lara AN, Tonácio AC, Mendes MF, Pereira SLA, Callegaro D. Reducing infection risk in multiple sclerosis and neuromyelitis optica spectrum disorders: a Brazilian reference center's approach. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1057-1066. [PMID: 36261129 PMCID: PMC9770084 DOI: 10.1055/s-0042-1754348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) are the most common autoimmune diseases of the central nervous system (CNS). They present chronic relapsing courses that demand treatment with disease-modifying drugs (DMDs) to prevent inflammatory activity. Disease-modifying drugs lead to immunomodulation or immunosuppression through diverse mechanisms (e.g., shifting lymphocyte and cytokine profile, suppressing specific lymphocyte subpopulations). Thus, patients are more prone to infectious complications and associated worsening of disease. OBJECTIVE To present feasible strategies for mitigating the infection risk of MS and NMOSD treated patients. METHODS Targeted literature review concerning the management of infection risk with an emphasis on vaccination, therapy-specific measures, and particularities of the Brazilian endemic infectious diseases' scenario. CONCLUSION We propose a vaccination schedule, infectious screening routine, and prophylactic measures based on the current scientific evidence. Awareness of emergent tropical diseases is necessary due to evidence of demyelinating events and possible parainfectious cases of MS and NMOSD.
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Affiliation(s)
| | - Lucas Bueno Feo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil
| | - Guilherme Diogo Silva
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil
| | - Caio César Diniz Disserol
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil
| | - Renata Barbosa Paolilo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil
| | - Amanda Nazareth Lara
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Doenças Infecciosas e Parasitárias, São Paulo SP, Brazil
| | - Adriana Coracini Tonácio
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Doenças Infecciosas e Parasitárias, São Paulo SP, Brazil
| | - Maria Fernanda Mendes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil,Faculdade de Ciências Mídicas, Santa Casa de São Paulo, Divisão de Neurologia, São Paulo SP, Brazil,Address for correspondence Maria Fernanda Mendes
| | | | - Dagoberto Callegaro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil
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4
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Tunbridge M, Perkins GB, Singer J, Salehi T, Ying T, Grubor-Bauk B, Barry S, Sim B, Hissaria P, Chadban SJ, Coates PT. Rapamycin and inulin for booster vaccine response stimulation (RIVASTIM)—rapamycin: study protocol for a randomised, controlled trial of immunosuppression modification with rapamycin to improve SARS-CoV-2 vaccine response in kidney transplant recipients. Trials 2022; 23:780. [PMID: 36109788 PMCID: PMC9477178 DOI: 10.1186/s13063-022-06634-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/04/2022] [Indexed: 11/10/2022] Open
Abstract
Kidney transplant recipients are at an increased risk of severe COVID-19-associated hospitalisation and death. Vaccination has been a key public health strategy to reduce disease severity and infectivity, but the effectiveness of COVID vaccines is markedly reduced in kidney transplant recipients. Urgent strategies to enhance vaccine efficacy are needed. Methods: RIVASTIM-rapamycin is a multicentre, randomised, controlled trial examining the effect of immunosuppression modification prior to a third dose of COVID-19 vaccine in kidney transplant recipients who have failed to develop protective immunity to a 2-dose COVID-19 vaccine schedule. Participants will be randomised 1:1 to either remain on standard of care immunosuppression with tacrolimus, mycophenolate, and prednisolone (control) or cease mycophenolate and commence sirolimus (intervention) for 4 weeks prior to and following vaccination. The primary outcome is the proportion of participants in each trial arm who develop protective serological neutralisation of live SARS-CoV-2 virus at 4–6 weeks following a third COVID-19 vaccination. Secondary outcomes include SARS-CoV-receptor binding domain IgG, vaccine-specific immune cell populations and responses, and the safety and tolerability of sirolimus switch. Discussion: Immunosuppression modification strategies may improve immunological vaccine response. We hypothesise that substituting the mTOR inhibitor sirolimus for mycophenolate in a triple drug regimen will enhance humoral and cell-mediated responses to COVID vaccination for kidney transplant recipients. Trial registration: Australia New Zealand Clinical Trials Registry ACTRN12621001412820. Registered on 20 October 2021; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382891&isReview=true
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5
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Joerns J, Bollineni S, Mahan LD, Mohanka MR, Lawrence A, Timofte I, Torres F, La Hoz RM, Zhang S, Kershaw CD, Kaza V, Terada LS, Banga A. High-dose Mycophenolate Use at Vaccination Is Independently Associated With Breakthrough COVID-19 Among Lung Transplant Patients. Transplantation 2022; 106:e271-e274. [PMID: 35250007 PMCID: PMC9038231 DOI: 10.1097/tp.0000000000004089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/19/2021] [Accepted: 01/03/2022] [Indexed: 11/25/2022]
Affiliation(s)
- John Joerns
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Srinivas Bollineni
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Luke D. Mahan
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Manish R. Mohanka
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Adrian Lawrence
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Irina Timofte
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ricardo M. La Hoz
- Division of Infectious Disease and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Song Zhang
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Corey D. Kershaw
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Vaidehi Kaza
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lance S. Terada
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Amit Banga
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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6
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Vaccinations in Patients with Rheumatic Disease: Consider Disease and Therapy. Rheum Dis Clin North Am 2022; 48:397-409. [PMID: 35400367 DOI: 10.1016/j.rdc.2022.02.001] [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: 11/23/2022]
Abstract
Patients with rheumatic diseases are susceptible to infections due to their underlying disease states as well as from immunosuppressive medications, highlighting the importance of vaccination, these same factors also pose challenges to vaccine efficacy, safety, and uptake. This article reviews the impact of immunosuppressive therapies and rheumatic disease on vaccine efficacy in this vulnerable patient population as well as discusses best practices.
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7
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Ma BM, Tam AR, Chan KW, Ma MKM, Hung IFN, Yap DYH, Chan TM. Immunogenicity and Safety of COVID-19 Vaccines in Patients Receiving Renal Replacement Therapy: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:827859. [PMID: 35355604 PMCID: PMC8959490 DOI: 10.3389/fmed.2022.827859] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/09/2022] [Indexed: 01/11/2023] Open
Abstract
Background Systematic data on the efficacy and safety of COVID-19 vaccine in patients on renal replacement therapy (RRT) remains limited. We conducted a meta-analysis on the efficacy and safety of COVID-19 vaccine in patients on RRT. Methods Eligible studies were identified by systematic literature search in four electronic databases. Twenty-seven studies (4,264 patients) were included for meta-analysis. 99% patients received mRNA vaccine. Results Patients on RRT showed inferior seropositivity after two-dosed COVID-19 vaccine, 44% lower than the general population. Kidney transplant recipients (KTRs) had significantly lower seropositivity than patients on haemodialysis (HD) or peritoneal dialysis (PD) (26.1 vs. 84.3% and 92.4% respectively, p < 0.001 for both). Compared with healthy controls, KTRs, HD and PD patients were 80% (95% CI: 62–99%), 18% (95% CI: 9–27%) and 11% (95% CI: 1–21%) less likely to develop antibodies after vaccination (p < 0.001, <0.001 and 0.39 respectively). In KTRs, every 1% increase in using mycophenolate was associated with 0.92% reduction in seropositivity (95% CI: −1.68, −0.17, p = 0.021) at population level. The overall adverse event rate attributed to vaccination was 2.1%. Most events were mild. Conclusion Patients on RRT, particularly KTRs, had significantly reduced antibody response after two-dosed COVID-19 vaccination. Vaccination is generally well tolerated. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42021261879.
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Affiliation(s)
- Becky Mingyao Ma
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Anthony Raymond Tam
- Division of Infectious Diseases, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Kam Wa Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Maggie Kam Man Ma
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Ivan Fan Ngai Hung
- Division of Infectious Diseases, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Desmond Yat Hin Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Tak Mao Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
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8
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Bemben NM, Berg ML. Efficacy of inactivated vaccines in patients treated with immunosuppressive drug therapy. Pharmacotherapy 2022; 42:334-342. [PMID: 35146780 PMCID: PMC9088666 DOI: 10.1002/phar.2671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Nina M. Bemben
- Wolters Kluwer Clinical Effectiveness Chicago Illinois USA
| | - Melody L. Berg
- American Society of Health‐System Pharmacists Bethesda Maryland USA
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9
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Aryanian Z, Balighi K, Hatami P, Goodarzi A, Mohandesi NA, Afshar ZM. SARS-CoV-2 vaccination and practical points in psoriasis patients: a narrative review. Dermatol Ther 2022; 35:e15430. [PMID: 35261123 PMCID: PMC9111853 DOI: 10.1111/dth.15430] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/28/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022]
Abstract
SARS‐CoV2 vaccines were approved without long‐term monitoring due to emergent situations. This has raised some issues about timing and protocol of receiving vaccines in specific situations including patients with chronic inflammatory disorders such as psoriasis. Here, we present different aspects of SARS‐CoV‐2 infection and vaccination in psoriasis patients and aim to provide solutions to overcome the potential challenges. In brief, the benefits of vaccination outweigh the potential risk; vaccine‐triggered de novo or flares of psoriasis is uncommon. As such, all psoriasis patients, especially those receiving systemic treatments including anti tumor necrosis factor agents, are strongly recommended to get SARS‐CoV‐2 vaccines. It is recommended that new immunosuppressive/immunomodulatory therapies be initiated at least 1 week after the second SARS‐CoV‐2 vaccine dose, if possible. In addition, in severe and active forms of psoriasis, it is better to delay vaccination until stabilization of the disease.
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Affiliation(s)
- Zeinab Aryanian
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran.Tehran, Iran.,Department of Dermatology, Babol University of Medical Sciences, Babol, Iran
| | - Kamran Balighi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran.Tehran, Iran.,Department of Dermatology, School of Medicine Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parvaneh Hatami
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran.Tehran, Iran
| | - Azadeh Goodarzi
- Department of Dermatology, Rasoul-e- Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.,Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Zeinab Mohseni Afshar
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah, University of Medical Sciences, Kermanshah, Iran
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10
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Specker C, Aries P, Braun J, Burmester G, Fischer-Betz R, Hasseli R, Holle J, Hoyer BF, Iking-Konert C, Krause A, Krüger K, Krusche M, Leipe J, Lorenz HM, Moosig F, Schmale-Grede R, Schneider M, Strangfeld A, Voll R, Voormann A, Wagner U, Schulze-Koops H. Updated recommendations of the German Society for Rheumatology for the care of patients with inflammatory rheumatic diseases in the context of the SARS-CoV-2/COVID-19 pandemic, including recommendations for COVID-19 vaccination. Z Rheumatol 2021; 80:33-48. [PMID: 34491403 PMCID: PMC8422376 DOI: 10.1007/s00393-021-01055-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Christof Specker
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany.
- Klinik für Rheumatologie & Klinische Immunologie, Kliniken Essen-Mitte, Pattbergstr. 2, 45239, Essen, Germany.
| | - Peer Aries
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Rheumatologie im Struenseehaus, Hamburg, Germany
| | - Jürgen Braun
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Rheumazentrum Ruhrgebiet, Ruhr Universität Bochum, Bochum, Germany
| | - Gerd Burmester
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Freie Universität und Humboldt Universität zu Berlin, Berlin, Germany
| | - Rebecca Fischer-Betz
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Rebecca Hasseli
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Abteilung für Rheumatologie und Klinische Immunologie, Justus-Liebig-Universität Gießen, Campus Kerckhoff, Bad Nauheim, Germany
| | - Julia Holle
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - Bimba Franziska Hoyer
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Abteilung für Rheumatologie, 1. Medizinische Klinik, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Christof Iking-Konert
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- III. Medizinische Klinik und Poliklinik Sektion Rheumatologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
| | - Andreas Krause
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Abteilung für Rheumatologie, Osteologie und Klinische Immunologie, Immanuel Krankenhaus Berlin, Berlin, Germany
| | - Klaus Krüger
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Rheumatologisches Praxiszentrum München, Munich, Germany
| | - Martin Krusche
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Freie Universität und Humboldt Universität zu Berlin, Berlin, Germany
| | - Jan Leipe
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Abteilung für Rheumatologie, Medizinische Klinik V, Universitätskrankenhaus Mannheim, Mannheim, Germany
| | - Hanns-Martin Lorenz
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Frank Moosig
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | | | - Matthias Schneider
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Anja Strangfeld
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Programmbereich Epidemiologie und Versorgungsforschung, Deutsches Rheumaforschungszentrum Berlin, Berlin, Germany
| | - Reinhard Voll
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Klinik für Rheumatologie und Klinische Immunologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Universität Freiburg, Freiburg, Germany
| | - Anna Voormann
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
| | - Ulf Wagner
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany
- Abteilung für Rheumatologie, Klinik und Poliklinik für Endokrinologie, Nephrologie, Rheumatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Hendrik Schulze-Koops
- German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie e. V., DGRh), Berlin, Germany.
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik IV, Ludwig-Maximilians-Universität München, Pettenkoferstraße 8a, Munich, Germany.
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11
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Yeaman MR. Immunosuppression in Glomerular Diseases: Implications for SARS-CoV-2 Vaccines and COVID-19. GLOMERULAR DISEASES 2021; 1:277-293. [PMID: 34935004 PMCID: PMC8678218 DOI: 10.1159/000519182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/19/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Glomerular diseases (GD) are chronic conditions that often involve immune dysfunction and require immunosuppressive therapy (IST) to control underlying pathogenesis. Unfortunately, such diseases appear to heighten risks of severe outcomes in COVID-19 and predispose to other infections that may be life-threatening. Thus, averting preventable infections is imperative in GD patients. SUMMARY The advent of vaccines demonstrated to be safe and efficacious against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has favorably impacted the COVID-19 pandemic epidemiology. However, patients on ISTs were excluded from initial vaccine clinical trials. Thus, only limited and incomplete data are available currently regarding the potential impact of immunosuppression on immune response to or efficacy of the SARS-CoV-2 vaccines. However, new insights are emerging from SARS-CoV-2 vaccine studies, and impacts of ISTs on conventional vaccines are useful to consider. Mechanisms of immunosuppressive agents commonly used in the treatment of GD are reviewed with respect to implications for immune responses induced by SARS-CoV-2 vaccines. ISTs discussed include corticosteroids; alkylating agents; antimetabolites; calcineurin or mammalian target of rapamycin inhibitors; CD38+, CD20+, or CD19+ cell depletion; and complement protein C5 inhibition. KEY MESSAGES Many immunosuppressive therapies may potentially attenuate or impair protective immunity of the SARS-CoV-2 vaccines. However, as vaccines currently in use employ mRNA or nonreplicative viral vectors, they appear to be safe in patients on immunosuppression, further favoring vaccination. Moreover, predominant SARS-CoV-2 vaccines are likely to afford at least partial protective immunity through one or more immune mechanisms even in patients on IST. Guidelines and emerging strategies are also considered to optimize vaccine protection from COVID-19.
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Affiliation(s)
- Michael R. Yeaman
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Divisions of Molecular Medicine & Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, USA
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
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12
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Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, Calabrese C, Gravallese EM, Harpaz R, Kroger A, Sadun RE, Turner AS, Williams EA, Mikuls TR. American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 3. Arthritis Rheumatol 2021; 73:e60-e75. [PMID: 34346564 PMCID: PMC8426685 DOI: 10.1002/art.41928] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/10/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To provide guidance to rheumatology providers on the use of coronavirus disease 2019 (COVID-19) vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious disease specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS Despite a paucity of direct evidence, 74 draft guidance statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION These guidance statements, made in the context of limited clinical data, are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.
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Affiliation(s)
| | - Sindhu R. Johnson
- Toronto Western HospitalMount Sinai Hospital, and University of TorontoTorontoOntarioCanada
| | - Donald D. Anthony
- Louis Stokes Cleveland VA Medical CenterMetroHealth Medical Center, and Case Western Reserve UniversityClevelandOhioUnited States
| | - Reuben J. Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical CenterDallas
| | | | - Anne R. Bass
- Hospital for Special Surgery and Weill Cornell MedicineNew YorkNew YorkUnited States
| | | | | | - Rafael Harpaz
- Harpaz Herman ConsultantsAtlantaGeorgiaUnited States
| | | | | | - Amy S. Turner
- American College of RheumatologyAtlantaGeorgiaUnited States
| | | | - Ted R. Mikuls
- University of Nebraska Medical Center and VA Nebraska–Western Iowa Health Care SystemOmaha
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13
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Hasseli R, Pfeil A, Krause A, Schulze-Koops H, Müller-Ladner U, Specker C. A survey to evaluate knowledge, perceptions and attitudes toward COVID-19 vaccinations among rheumatologists in Germany. Rheumatol Int 2021; 41:1949-1956. [PMID: 34498112 PMCID: PMC8425463 DOI: 10.1007/s00296-021-04986-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/30/2021] [Indexed: 12/12/2022]
Abstract
The objective is to evaluate the attitude of rheumatologists regarding the use of COVID-19 vaccination in patients with inflammatory rheumatic diseases (IRDs). From February 2nd until March 15th, 2021, rheumatologists from Germany were asked to participate anonymously in a survey addressing their attitude with respect to COVID-19 vaccinations of IRD patients. The survey was completed by 214 participants (107 men, 103 women, 4 unspecified). More than half of the physicians (61%) were working in rheumatologic private practices and 62% had more than 20 years of experience in rheumatology. 90% reported to be at least confidential in handling issues of COVID-19 vaccination and 99% would recommend COVID-19 vaccination for IRD patients. The majority would not recommend to stop or reduce immunomodulatory drugs for vaccination except for rituximab. More than 70% would prefer vaccination with a mRNA vaccine for their IRD patients. This study shows that almost all rheumatologists in Germany support the COVID-19 vaccination for their IRD patients without reducing or terminating the actual immunomodulatory medication to potentially improve the response to the vaccine. This attitude is in accordance with the current recommendations of the German Society of Rheumatology regarding COVID-19 vaccination in IRD patients, and indicates that these have been well accepted and work in everyday clinical practice.
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Affiliation(s)
- Rebecca Hasseli
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus-Liebig-University Giessen, Bad Nauheim, Germany.
| | - Alexander Pfeil
- Department of Internal Medicine III, University Hospital Jena, Jena, Germany
| | - Andreas Krause
- Department of Rheumatology, Clinical Immunology and Osteology, Immanuel Hospital, Berlin, Germany
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV, University of Munich, Munich, Germany
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus-Liebig-University Giessen, Bad Nauheim, Germany
| | - Christof Specker
- Department of Rheumatology and Clinical Immunology, Kliniken Essen-Mitte, Essen, Germany
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14
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Speeckaert R, Lambert J, Puig L, Speeckaert M, Lapeere H, De Schepper S, van Geel N. Vaccinations in Patients Receiving Systemic Drugs for Skin Disorders: What Can We Learn for SARS-Cov-2 Vaccination Strategies? Drugs R D 2021; 21:341-350. [PMID: 34106430 PMCID: PMC8188745 DOI: 10.1007/s40268-021-00349-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 01/20/2023] Open
Abstract
Large-scale vaccination strategies are currently being deployed against severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2). Whether systemic medication for skin diseases affects the efficacy of vaccination and whether temporary interruption or extension of the dosing interval is necessary is under debate. Most immunomodulating/immunosuppressive drugs only affect vaccine-induced immune responses to a limited or moderate extent, preserving sufficient immunity in most patients. Mycophenolate mofetil, Janus kinase inhibitors, and rituximab require a more cautious approach, and judicious timing of vaccination might be appropriate in patients receiving these treatments. It should be noted that, for most drugs except methotrexate, data on the length of the interruption period to restore vaccine-induced immune responses to normal levels are either very limited or absent. In these cases, only the drug half-life can be used as a practical guideline. In most patients, systemic medication can be continued through the vaccination process, although case-by-case decisions can be considered.
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Affiliation(s)
- Reinhart Speeckaert
- Department of Dermatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Jo Lambert
- Department of Dermatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Luis Puig
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Hilde Lapeere
- Department of Dermatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Sofie De Schepper
- Department of Dermatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Nanja van Geel
- Department of Dermatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
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15
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Scharringa S, Hoffman T, van Kessel DA, Rijkers GT. Vaccination and their importance for lung transplant recipients in a COVID-19 world. Expert Rev Clin Pharmacol 2021; 14:1413-1425. [PMID: 34328054 DOI: 10.1080/17512433.2021.1961577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Lung transplant patients are immunocompromised because of the medication they receive to prevent rejection, and as a consequence are susceptible to (respiratory) infections. Adequate vaccination strategies, including COVID-19 vaccination, are therefore needed to minimize infection risks. AREAS COVERED The international vaccination guidelines for lung transplant patients are reviewed, including the data on immunogenicity and effectivity of the vaccines. The impact on response to vaccination of the various categories of immunosuppressive drugs, used in the posttransplant period, on response to vaccination is described. A number of immunosuppressive and/or anti-inflammatory drugs also is used for controlling the immunopathology of severe COVID-19. Current available COVID-19 vaccines, both mRNA or adenovirus based are recommended for lung transplant patients. EXPERT OPINION In order to improve survival and quality of life, infections of lung transplant patients should be prevented by vaccination. When possible, vaccination should start already during the pre-transplantation period when the patient is on the waiting list. Booster vaccinations should be given post-transplantation, but only when immunosuppression has been tapered. Vaccine design based on mRNA technology could allow the design of an array of vaccines against other respiratory viruses, offering a better protection for lung transplant patients.
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Affiliation(s)
- Samantha Scharringa
- Department of Sciences, University College Roosevelt, Middelburg, The Netherlands
| | - Thijs Hoffman
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Diana A van Kessel
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Ger T Rijkers
- Department of Sciences, University College Roosevelt, Middelburg, The Netherlands.,Microvida Laboratory for Medical Microbiology and Immunology, St. Elisabeth Hospital, Tilburg, The Netherlands
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16
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Arnold J, Winthrop K, Emery P. COVID-19 vaccination and antirheumatic therapy. Rheumatology (Oxford) 2021; 60:3496-3502. [PMID: 33710296 PMCID: PMC7989162 DOI: 10.1093/rheumatology/keab223] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/18/2021] [Accepted: 03/01/2021] [Indexed: 12/27/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) vaccination will be the largest vaccination programme in the history of the NHS. Patients on immunosuppressive therapy will be among the earliest to be vaccinated. Some evidence indicates immunosuppressive therapy inhibits humoral response to the influenza, pneumococcal and hepatitis B vaccines. The degree to which this will translate to impaired COVID-19 vaccine responses is unclear. Other evidence suggests withholding MTX for 2 weeks post-vaccination may improve responses. Rituximab has been shown to impair humoral responses for 6 months or longer post-administration. Decisions on withholding or interrupting immunosuppressive therapy around COVID-19 vaccination will need to be made prior to the availability of data on specific COVID-19 vaccine response in these patients. With this in mind, this article outlines the existing data on the effect of antirheumatic therapy on vaccine responses in patients with inflammatory arthritis and formulates a possible pragmatic management strategy for COVID-19 vaccination.
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Affiliation(s)
- Jack Arnold
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - Kevin Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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17
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Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, Calabrese C, Gravallese EM, Harpaz R, Kroger A, Sadun RE, Turner AS, Williams EA, Mikuls TR. American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 2. Arthritis Rheumatol 2021; 73:e30-e45. [PMID: 34128356 PMCID: PMC8427105 DOI: 10.1002/art.41877] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/10/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To provide guidance to rheumatology providers on the use of coronavirus disease 2019 (COVID-19) vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious disease specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS Despite a paucity of direct evidence, 74 draft guidance statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION These guidance statements, made in the context of limited clinical data, are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.
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Affiliation(s)
| | - Sindhu R. Johnson
- Toronto Western HospitalMount Sinai Hospital, and University of TorontoTorontoOntarioCanada
| | - Donald D. Anthony
- Louis Stokes Cleveland VA Medical CenterMetroHealth Medical Center, and Case Western Reserve UniversityClevelandOhioUnited States
| | - Reuben J. Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical CenterDallas
| | | | - Anne R. Bass
- Hospital for Special Surgery and Weill Cornell MedicineNew YorkNew YorkUnited States
| | | | | | - Rafael Harpaz
- Harpaz Herman ConsultantsAtlantaGeorgiaUnited States
| | | | | | - Amy S. Turner
- American College of RheumatologyAtlantaGeorgiaUnited States
| | | | - Ted R. Mikuls
- University of Nebraska Medical Center and VA Nebraska–Western Iowa Health Care SystemOmaha
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18
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Specker C, Aries P, Braun J, Burmester G, Fischer-Betz R, Hasseli R, Holle J, Hoyer BF, Iking-Konert C, Krause A, Krüger K, Krusche M, Leipe J, Lorenz HM, Moosig F, Schmale-Grede R, Schneider M, Strangfeld A, Voll R, Voormann A, Wagner U, Schulze-Koops H. [Updated recommendations of the German Society for Rheumatology for the care of patients with inflammatory rheumatic diseases in the context of the SARS-CoV‑2/COVID‑19 pandemic, including recommendations for COVID‑19 vaccination]. Z Rheumatol 2021; 80:570-587. [PMID: 34309739 PMCID: PMC8311067 DOI: 10.1007/s00393-021-01056-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Christof Specker
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland.
- Klinik für Rheumatologie und Klinische Immunologie, Kliniken Essen-Mitte, Pattbergstr. 2, 45239, Essen, Deutschland.
| | - Peer Aries
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Rheumatologie im Struenseehaus, Hamburg, Deutschland
| | - Jürgen Braun
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Rheumazentrum Ruhrgebiet, Ruhr Universität Bochum, Bochum, Deutschland
| | - Gerd Burmester
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Freie Universität und Humboldt Universität zu Berlin, Berlin, Deutschland
| | - Rebecca Fischer-Betz
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, , Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Rebecca Hasseli
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Abteilung für Rheumatologie und Klinische Immunologie, Justus-Liebig-Universität Gießen, Campus Kerckhoff, Bad Nauheim, Deutschland
| | - Julia Holle
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | - Bimba Franziska Hoyer
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Abteilung für Rheumatologie, 1. Medizinische Klinik, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Christof Iking-Konert
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- III. Medizinische Klinik und Poliklinik Sektion Rheumatologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg-Eppendorf, Deutschland
| | - Andreas Krause
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Abteilung für Rheumatologie, Osteologie und Klinische Immunologie, Immanuel Krankenhaus Berlin, Berlin, Deutschland
| | - Klaus Krüger
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Rheumatologisches Praxiszentrum München, München, Deutschland
| | - Martin Krusche
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Freie Universität und Humboldt Universität zu Berlin, Berlin, Deutschland
| | - Jan Leipe
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Abteilung für Rheumatologie, Medizinische Klinik V, Universitätskrankenhaus Mannheim, Mannheim, Deutschland
| | - Hanns-Martin Lorenz
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Frank Moosig
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | | | - Matthias Schneider
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, , Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Anja Strangfeld
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Programmbereich Epidemiologie und Versorgungsforschung, Deutsches Rheumaforschungszentrum Berlin, Berlin, Deutschland
| | - Reinhard Voll
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Klinik für Rheumatologie und Klinische Immunologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland
| | - Anna Voormann
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
| | - Ulf Wagner
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland
- Abteilung für Rheumatologie, Klinik und Poliklinik für Endokrinologie, Nephrologie, Rheumatologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Hendrik Schulze-Koops
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Deutschland.
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik IV, Ludwig-Maximilians-Universität München, Pettenkoferstr. 8a, 80336, München, Deutschland.
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19
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Abstract
Patients with rheumatic diseases are susceptible to infections due to their underlying disease states as well as from immunosuppressive medications, highlighting the importance of vaccination, these same factors also pose challenges to vaccine efficacy, safety, and uptake. This article reviews the impact of immunosuppressive therapies and rheumatic disease on vaccine efficacy in this vulnerable patient population as well as discusses best practices.
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Affiliation(s)
- Cassandra Calabrese
- Department of Rheumatologic & Immunologic Disease, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A50, Cleveland, OH 44195, USA.
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20
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Rick J, Thompson AM, Hsiao JL, Liao W, Shi VY. Immunosuppressants, immunomodulators and COVID-19 vaccines: anticipating patient concerns. J DERMATOL TREAT 2021; 33:1794-1797. [PMID: 33494626 DOI: 10.1080/09546634.2021.1880543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jonathan Rick
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Jennifer L Hsiao
- Department of Medicine, Division of Dermatology, University of California Los Angeles, Los Angeles, CA, USA
| | - Wilson Liao
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
| | - Vivian Y Shi
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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21
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Gresham LM, Marzario B, Dutz J, Kirchhof MG. An evidence-based guide to SARS-CoV-2 vaccination of patients on immunotherapies in dermatology. J Am Acad Dermatol 2021; 84:1652-1666. [PMID: 33482251 PMCID: PMC7816618 DOI: 10.1016/j.jaad.2021.01.047] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 12/15/2022]
Abstract
Immune-mediated diseases and immunotherapeutics can negatively affect normal immune functioning and, consequently, vaccine safety and response. The COVID-19 pandemic has incited research aimed at developing a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. As SARS-CoV-2 vaccines are developed and made available, the assessment of anticipated safety and efficacy in patients with immune-mediated dermatologic diseases and requiring immunosuppressive and/or immunomodulatory therapy is particularly important. A review of the literature was conducted by a multidisciplinary committee to provide guidance on the safety and efficacy of SARS-CoV-2 vaccination for dermatologists and other clinicians when prescribing immunotherapeutics. The vaccine platforms being used to develop SARS-CoV-2 vaccines are expected to be safe and potentially effective for dermatology patients on immunotherapeutics. Current guidelines for the vaccination of an immunocompromised host remain appropriate when considering future administration of SARS-CoV-2 vaccines.
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Affiliation(s)
- Louise M Gresham
- Division of Dermatology, Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada
| | - Barbara Marzario
- Division of Dermatology, Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada
| | - Jan Dutz
- Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, Canada
| | - Mark G Kirchhof
- Division of Dermatology, Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada.
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22
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Khishigsuren B, Demir E, Akgul S, Temurhan S, Ucar A, Dirim A, Catikkas N, Bayraktar A, Caliskan Y, Yazici H, Oguz F, Turkmen A, Sever M. Panel Reactive Antibody Responses Against Influenza Vaccination in Kidney Transplant Recipients. Transplant Proc 2019; 51:1115-1117. [DOI: 10.1016/j.transproceed.2019.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/09/2019] [Accepted: 02/16/2019] [Indexed: 11/15/2022]
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23
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Kinetics of antibody response to influenza vaccination in renal transplant recipients. Transpl Immunol 2019; 53:51-60. [PMID: 30664927 DOI: 10.1016/j.trim.2019.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 12/27/2022]
Abstract
Annual vaccination is routinely used in organ transplant recipients for immunization against seasonal influenza. However, detailed analysis of the kinetics of vaccine-induced immune responses in this population is lacking. In this study, we investigated the kinetics of vaccine strains-specific antibody responses to trivalent influenza vaccine in a group of renal transplant recipients and a control group. First, we found that the geometric mean hemagglutination inhibition titer against all 3 vaccine strains in the transplant cohort was significantly low when compared to control subjects. Next, whereas the control group sera showed significantly higher HA-specific IgG and isotype IgG1 antibodies at all four time points, a similar increase in the transplant group was delayed until day 28. Interestingly, within the transplant group, subjects receiving belatacept/MMF/prednisone-based regimen had significantly lower levels of total IgG and HA-specific IgG when compared to tacrolimus/MMF/prednisone-based regimen. Even though IgG-ASC response in both cohorts peaked at day 7 post-vaccination, the frequency of IgG-ASC was significantly low in the transplant group. Taken together, our studies show delayed kinetics and lower levels of influenza vaccine-specific antibody responses in renal transplant recipients and, more importantly, indicate the need to probe and improve current vaccination strategies in renal transplant recipients.
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Papp KA, Haraoui B, Kumar D, Marshall JK, Bissonnette R, Bitton A, Bressler B, Gooderham M, Ho V, Jamal S, Pope JE, Steinhart AH, Vinh DC, Wade J. Vaccination Guidelines for Patients With Immune-Mediated Disorders on Immunosuppressive Therapies. J Cutan Med Surg 2018; 23:50-74. [PMID: 30463418 PMCID: PMC6330697 DOI: 10.1177/1203475418811335] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND: Patients with immune-mediated diseases on immunosuppressive therapies have more infectious episodes than healthy individuals, yet vaccination practices by physicians for this patient population remain suboptimal. OBJECTIVES: To evaluate the safety and efficacy of vaccines in individuals exposed to immunosuppressive therapies and provide evidence-based clinical practice recommendations. METHODS: A literature search for vaccination safety and efficacy in patients on immunosuppressive therapies (2009-2017) was conducted. Results were assessed using the Grading of Recommendation, Assessment, Development, and Evaluation system. RESULTS: Several immunosuppressive therapies attenuate vaccine response. Thus, vaccines should be administered before treatment whenever feasible. Inactivated vaccines can be administered without treatment discontinuation. Similarly, evidence suggests that the live zoster vaccine is safe and effective while on select immunosuppressive therapy, although use of the subunit vaccine is preferred. Caution regarding other live vaccines is warranted. Drug pharmacokinetics, duration of vaccine-induced viremia, and immune response kinetics should be considered to determine appropriate timing of vaccination and treatment (re)initiation. Infants exposed to immunosuppressive therapies through breastmilk can usually be immunized according to local guidelines. Intrauterine exposure to immunosuppressive agents is not a contraindication for inactivated vaccines. Live attenuated vaccines scheduled for infants and children ⩾12 months of age, including measles, mumps, rubella, and varicella, can be safely administered as sufficient time has elapsed for drug clearance. CONCLUSIONS: Immunosuppressive agents may attenuate vaccine responses, but protective benefit is generally maintained. While these recommendations are evidence based, they do not replace clinical judgment, and decisions regarding vaccination must carefully assess the risks, benefits, and circumstances of individual patients.
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Affiliation(s)
- Kim A Papp
- 1 K Papp Clinical Research, Waterloo, ON, Canada.,2 Probity Medical Research, Waterloo, ON, Canada
| | - Boulos Haraoui
- 3 Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Deepali Kumar
- 4 University Health Network, Toronto, ON, Canada.,5 Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - John K Marshall
- 6 Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | | | - Alain Bitton
- 8 McGill University Health Centre, Montreal, QC, Canada
| | - Brian Bressler
- 9 Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,10 St Paul's Hospital, Vancouver, BC, Canada
| | - Melinda Gooderham
- 2 Probity Medical Research, Waterloo, ON, Canada.,11 Faculty of Medicine, Queen's University, Kingston, ON, Canada
| | - Vincent Ho
- 9 Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shahin Jamal
- 12 Vancouver Coastal Health, Vancouver, BC, Canada
| | - Janet E Pope
- 13 Faculty of Medicine, University of Western Ontario, London, ON, Canada.,14 St Joseph's Health Care, London, ON, Canada
| | - A Hillary Steinhart
- 5 Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,15 Mount Sinai Hospital, Toronto, ON, Canada
| | - Donald C Vinh
- 8 McGill University Health Centre, Montreal, QC, Canada.,16 Research Institute, McGill University Health Centre, Montreal, QC, Canada
| | - John Wade
- 9 Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,17 Vancouver General Hospital, Vancouver, BC, Canada
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Immunogenicity and safety of double versus standard dose of the seasonal influenza vaccine in solid-organ transplant recipients: A randomized controlled trial. Vaccine 2018; 36:6163-6169. [PMID: 30181045 DOI: 10.1016/j.vaccine.2018.08.057] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/16/2018] [Accepted: 08/22/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of vaccines with higher doses of antigen is an attractive strategy to improve the immunogenicity of influenza vaccination in transplant recipients. However, the effect of vaccination with a double-dose (DD) containing 30 µg of antigen in this population remains unknown. METHODS We performed a randomized controlled trial to compare the immunogenicity and safety of DD (30 µg) vs. standard dose (SD, 15 µg) of a trivalent inactivated influenza vaccine in kidney and liver transplant recipients. Immunogenicity was assessed by hemagglutination-inhibition assay. Vaccine response was defined as seroconversion to at least one viral strain 2 weeks after vaccination and seroprotection as a titer ≥40. RESULTS Sixty-three kidney and 16 liver transplant recipients were enrolled. Forty patients received the DD and 39 the SD vaccine. Overall, 40% of patients in the DD compared to 26% in the SD group (P = 0.174) responded to vaccine. In the DD arm, more patients were seroprotected to all viral strains after vaccination (88% vs 69%, P = 0.048). Post vaccination geometric mean titers of antibodies were 131.9 vs. 89.7 (P = 0.187) for H1N1, 185.4 vs. 138.7 (P = 0.182) for H3N2, and 96.6 vs. 68.8 (P = 0.081) for influenza B with the DD vs. SD. In both groups, most of the adverse events were mild and no vaccine-related severe adverse events were observed. CONCLUSION Double-dose influenza vaccine is safe and may increase antibody response in transplant recipients. In this population, DD vaccination could be an alternative when high-dose vaccine is not available. NCT02746783.
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Mulley WR, Dendle C, Ling JEH, Knight SR. Does vaccination in solid-organ transplant recipients result in adverse immunologic sequelae? A systematic review and meta-analysis. J Heart Lung Transplant 2018; 37:844-852. [PMID: 29609844 DOI: 10.1016/j.healun.2018.03.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/27/2017] [Accepted: 03/07/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Clinical guidelines recommend vaccinations for solid-organ transplant recipients. However, concern exists that vaccination may stimulate adverse alloimmune responses. METHODS We systematically reviewed the published literature regarding this aspect of vaccine safety. Electronic databases were searched for interventional and observational studies assessing de novo donor-specific antibodies (DSA) and rejection episodes after vaccination against infectious pathogens. Graft loss was also assessed. A meta-analysis was conducted for prospective, controlled studies. PRISMA reporting guidelines were followed. RESULTS Ninety studies (15,645 vaccinated patients and 42,924 control patients) were included. Twelve studies included control groups. The incidence of de novo DSA (14 studies) was 23 of 1,244 patients (1.85%) at 21 to 94 days. The incidence of rejection (83 studies) was 107 episodes in 5,116 patients (2.1%) at 0.7 to 6 months. Meta-analysis of prospective controlled studies (n = 8) showed no increased rejection risk with vaccination compared with no vaccination (RR 1.12, 95% CI 0.75 to 1.70). This finding was supported by data from 3 registry analyses. CONCLUSIONS Although the current evidence lacks high-quality, controlled studies, the currently available data provide reassurance that clinicians should recommend appropriate vaccination for their transplant patients as the risk of de novo DSA and rejection is relatively low.
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Affiliation(s)
- William R Mulley
- Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia; Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia.
| | - Claire Dendle
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia; Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia
| | - Jonathan E H Ling
- Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia; Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Simon R Knight
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Centre for Evidence in Transplantation, Royal College of Surgeons of England, London, UK
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Wiedermann U, Sitte HH, Burgmann H, Eser A, Falb P, Holzmann H, Kitchen M, Köller M, Kollaritsch H, Kundi M, Lassmann H, Mutz I, Pickl WF, Riedl E, Sibilia M, Thalhammer F, Tucek B, Zenz W, Zwiauer K. [Guidelines for vaccination of immunocompromised individuals]. Wien Klin Wochenschr 2016; 128 Suppl 4:337-76. [PMID: 27457874 DOI: 10.1007/s00508-016-1033-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 06/04/2016] [Indexed: 12/14/2022]
Abstract
Immunosuppression of various origins is associated with an increased risk of infection; therefore the prevention of infectious diseases by vaccination is especially important in immunocompromised patients. However, the response to vaccinations is often reduced in these risk groups and the application of live vaccines is contraindicated during immunosuppression.In the following expert statement, recommendations for vaccination were created on the basis of current evidence and theoretical/immunological considerations. A first, general part elaborates on efficacy and safety of vaccinations during immunosuppression, modes of action of immunosuppressive medications and recommended time intervals between immunosuppressive treatments and vaccinations. A core piece of this part is a graduation of immunosuppression into three stages, i. e. no relevant immunosuppression, mild to moderate and severe immunosuppression and the assignment of various medications (including biologicals) to one of those stages; this is followed by an overview of possible and necessary vaccinations in each of those stages.The second part gives detailed vaccination guidelines for common diseases and therapies associated with immunosuppression. Primary immune deficiencies, chronic kidney disease, diabetes mellitus, solid and hematological tumors, hematopoetic stem cell transplantation, transplantation of solid organs, aspenia, rheumatological-, gastroenterologic-, dermatologic-, neurologic diseases, biologicals during pregnancy and HIV infection are dealt with.These vaccination guidelines, compiled for the first time in Austria, aim to be of practical help for physicians to facilitate and improve vaccination coverage in immunocompromised patients and their household members and contact persons.
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Affiliation(s)
- Ursula Wiedermann
- Institut für Spezifische Prophylaxe und Tropenmedizin, Medizinische Universität Wien, Kinderspitalgasse 15, 1090, Wien, Österreich.
| | - Harald H Sitte
- Institut für Pharmakologie, Medizinische Universität Wien, Wien, Österreich
| | - Heinz Burgmann
- Klinische Abteilung für Infektionen und Tropenmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Alexander Eser
- Klinische Abteilung für Gastroenterologie und Hepatologie, Medizinische Universität Wien, Wien, Österreich
| | - Petra Falb
- Medizinmarktaufsicht, Agentur für Gesundheit und Ernährungssicherheit, Wien, Österreich
| | | | - Maria Kitchen
- Universitätsklinik für Dermatologie und Venerologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Marcus Köller
- Sozialmedizinisches Zentrum Sophienspital, Wien, Österreich
| | - Herwig Kollaritsch
- Institut für Spezifische Prophylaxe und Tropenmedizin, Medizinische Universität Wien, Kinderspitalgasse 15, 1090, Wien, Österreich
| | - Michael Kundi
- Institut für Umwelthygiene, Medizinische Universität Wien, Wien, Österreich
| | - Hans Lassmann
- Abteilung für Neuroimmunologie, Medizinische Universität Wien, Wien, Österreich
| | | | - Winfried F Pickl
- Institut für Immunologie, Medizinische Universität Wien, Wien, Österreich
| | - Elisabeth Riedl
- Universitätsklinik für Dermatologie, Medizinische Universität Wien, Wien, Österreich
| | - Maria Sibilia
- Institut für Krebsforschung, Medizinische Universität Wien, Wien, Österreich
| | - Florian Thalhammer
- Klinische Abteilung für Infektionen und Tropenmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Barbara Tucek
- Medizinmarktaufsicht, Agentur für Gesundheit und Ernährungssicherheit, Wien, Österreich
| | - Werner Zenz
- Klinische Abteilung für allgemeine Pädiatrie, Medizinische Universität Graz, Graz, Österreich
| | - Karl Zwiauer
- Klinische Abteilung für Kinder- und Jugendheilkunde, Universitätsklinikum St. Pölten, St. Pölten, Österreich
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Héquet D, Pascual M, Lartey S, Pathirana RD, Bredholt G, Hoschler K, Hullin R, Meylan P, Cox RJ, Manuel O. Humoral, T-cell and B-cell immune responses to seasonal influenza vaccine in solid organ transplant recipients receiving anti-T cell therapies. Vaccine 2016; 34:3576-83. [PMID: 27219339 DOI: 10.1016/j.vaccine.2016.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 04/29/2016] [Accepted: 05/09/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND We analyzed the impact of the anti-T-cell agents basiliximab and antithymocyte globulins (ATG) on antibody and cell-mediated immune responses after influenza vaccination in solid-organ transplant recipients. METHODS 71 kidney and heart transplant recipients (basiliximab [n=43] and ATG [n=28]) received the trivalent influenza vaccine. Antibody responses were measured at baseline and 6 weeks post-vaccination by hemagglutination inhibition assay; T-cell responses were measured by IFN-γ ELISpot assays and intracellular cytokine staining (ICS); and influenza-specific memory B-cell (MBC) responses were evaluated using ELISpot. RESULTS Median time of vaccination from transplantation was 29 months (IQR 8-73). Post-vaccination seroconversion rates were 26.8% for H1N1, 34.1% for H3N2 and 4.9% for influenza B in the basiliximab group and 35.7% for H1N1, 42.9% for H3N2 and 14.3% for influenza B in the ATG group (p=0.44, p=0.61, and p=0.21, respectively). The number of influenza-specific IFN-γ-producing cells increased significantly after vaccination (from 35 to 67.5 SFC/10(6) PBMC, p=0.0007), but no differences between treatment groups were observed (p=0.88). Median number of IgG-MBC did not increase after vaccination (H1N1, p=0.94; H3N2 p=0.34; B, p=0.79), irrespective of the type of anti-T-cell therapy. CONCLUSIONS After influenza vaccination, a significant increase in antibody and T-cell immune responses but not in MBC responses was observed in transplant recipients. Immune responses were not significantly different between groups that received basiliximab or ATG.
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Affiliation(s)
- Delphine Héquet
- Transplantation Center, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland; Infectious Diseases Service, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland.
| | - Manuel Pascual
- Transplantation Center, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Sarah Lartey
- Influenza Centre, Department of Clinical Science, University of Bergen, Norway
| | - Rishi D Pathirana
- Influenza Centre, Department of Clinical Science, University of Bergen, Norway
| | - Geir Bredholt
- Influenza Centre, Department of Clinical Science, University of Bergen, Norway
| | - Katja Hoschler
- Public Health England, Microbiology Services Colindale, London, United Kingdom
| | - Roger Hullin
- Division of Cardiology, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Pascal Meylan
- Infectious Diseases Service, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland; Institute of Microbiology, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Rebecca J Cox
- Influenza Centre, Department of Clinical Science, University of Bergen, Norway; Department of Research and Development, Haukeland University Hospital, Bergen, Norway; Jebsen Centre for Influenza Vaccine Research, University of Bergen, Norway
| | - Oriol Manuel
- Transplantation Center, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland; Infectious Diseases Service, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
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29
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Vaccination of Adult Patients with Systemic Lupus Erythematosus in Portugal. Int J Rheumatol 2016; 2016:2845617. [PMID: 27069477 PMCID: PMC4812392 DOI: 10.1155/2016/2845617] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 02/16/2016] [Indexed: 12/16/2022] Open
Abstract
In the wake of the Portuguese vaccination program 50th anniversary it seems appropriate to review vaccination in patients with systemic lupus erythematosus. Controversial issues as regards the association between autoimmune diseases, infections, and vaccines are discussed as well as vaccine safety and efficacy issues as regards chronic immunosuppressant (IS) drug therapy. After a brief overview of national policies, specific recommendations are made as regards vaccination for adult patients with SLE with a particular focus on current IS therapy and unmet needs.
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30
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Egli A, Humar A, Widmer LA, Lisboa LF, Santer DM, Mueller T, Stelling J, Baluch A, O'Shea D, Houghton M, Kumar D. Effect of Immunosuppression on T-Helper 2 and B-Cell Responses to Influenza Vaccination. J Infect Dis 2015; 212:137-46. [DOI: 10.1093/infdis/jiv015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 12/23/2014] [Indexed: 12/23/2022] Open
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31
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McMahan ZH, Bingham CO. Effects of biological and non-biological immunomodulatory therapies on the immunogenicity of vaccines in patients with rheumatic diseases. Arthritis Res Ther 2014; 16:506. [PMID: 25587634 PMCID: PMC4295484 DOI: 10.1186/s13075-014-0506-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Vaccinations are administered to patients to induce a protective immune response, resulting in immunological memory. Preventing infection through the use of vaccines is particularly important in immunocompromised and immunosuppressed individuals given their increased frequency and severity of infections relative to healthy individuals. Recent surveys show that the vaccination rate is still alarmingly low in patients with rheumatic disease. In this review we briefly discuss the different types of vaccines and then critically examine evidence related to vaccination efficacy in patients with autoimmune disease and the effects of immunomodulatory therapy, with an aim to provide guidance and optimize the administration of vaccines in such individuals.
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Pharmacology and toxicology of mycophenolate in organ transplant recipients: an update. Arch Toxicol 2014; 88:1351-89. [PMID: 24792322 DOI: 10.1007/s00204-014-1247-1] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/15/2014] [Indexed: 12/22/2022]
Abstract
This review aims to provide an update of the literature on the pharmacology and toxicology of mycophenolate in solid organ transplant recipients. Mycophenolate is now the antimetabolite of choice in immunosuppressant regimens in transplant recipients. The active drug moiety mycophenolic acid (MPA) is available as an ester pro-drug and an enteric-coated sodium salt. MPA is a competitive, selective and reversible inhibitor of inosine-5'-monophosphate dehydrogenase (IMPDH), an important rate-limiting enzyme in purine synthesis. MPA suppresses T and B lymphocyte proliferation; it also decreases expression of glycoproteins and adhesion molecules responsible for recruiting monocytes and lymphocytes to sites of inflammation and graft rejection; and may destroy activated lymphocytes by induction of a necrotic signal. Improved long-term allograft survival has been demonstrated for MPA and may be due to inhibition of monocyte chemoattractant protein 1 or fibroblast proliferation. Recent research also suggested a differential effect of mycophenolate on the regulatory T cell/helper T cell balance which could potentially encourage immune tolerance. Lower exposure to calcineurin inhibitors (renal sparing) appears to be possible with concomitant use of MPA in renal transplant recipients without undue risk of rejection. MPA displays large between- and within-subject pharmacokinetic variability. At least three studies have now reported that MPA exhibits nonlinear pharmacokinetics, with bioavailability decreasing significantly with increasing doses, perhaps due to saturable absorption processes or saturable enterohepatic recirculation. The role of therapeutic drug monitoring (TDM) is still controversial and the ability of routine MPA TDM to improve long-term graft survival and patient outcomes is largely unknown. MPA monitoring may be more important in high-immunological recipients, those on calcineurin-inhibitor-sparing regimens and in whom unexpected rejection or infections have occurred. The majority of pharmacodynamic data on MPA has been obtained in patients receiving MMF therapy in the first year after kidney transplantation. Low MPA area under the concentration time from 0 to 12 h post-dose (AUC0-12) is associated with increased incidence of biopsy-proven acute rejection although AUC0-12 optimal cut-off values vary across study populations. IMPDH monitoring to identify individuals at increased risk of rejection shows some promise but is still in the experimental stage. A relationship between MPA exposure and adverse events was identified in some but not all studies. Genetic variants within genes involved in MPA metabolism (UGT1A9, UGT1A8, UGT2B7), cellular transportation (SLCOB1, SLCO1B3, ABCC2) and targets (IMPDH) have been reported to effect MPA pharmacokinetics and/or response in some studies; however, larger studies across different ethnic groups that take into account genetic linkage and drug interactions that can alter a patient's phenotype are needed before any clinical recommendations based on patient genotype can be formulated. There is little data on the pharmacology and toxicology of MPA in older and paediatric transplant recipients.
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Goldacker S, Gause AM, Warnatz K. [Vaccination in adult patients with chronic inflammatory rheumatic diseases]. Z Rheumatol 2014; 72:690-4, 696-700, 702-4. [PMID: 23929239 DOI: 10.1007/s00393-013-1155-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Patients with chronic inflammatory rheumatic diseases often have an intrinsic and therapy associated increased susceptibility to infections which substantially contributes to morbidity and mortality of the patients. A large proportion of these infections are preventable by vaccination. For this reason in 2005 the standing vaccination committee (STIKO) recommended for patients with immunosuppression vaccination against pneumococcus, influenza, Haemophilus influenza b and meningococcus in addition to standard vaccinations, independent of age. Every patient should therefore be informed about a possible increase in susceptibility to infections and the recommended prevention by vaccination before implementation of immunosuppressive therapy.
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Affiliation(s)
- S Goldacker
- Centrum für Chronische Immmundefizienz, Universitätsklinikum Freiburg und Universität Freiburg, Breisacher Str. 117 - 2. OG, 79106, Freiburg, Deutschland.
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35
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Zbinden D, Manuel O. Influenza vaccination in immunocompromised patients: efficacy and safety. Immunotherapy 2014; 6:131-9. [DOI: 10.2217/imt.13.171] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Yearly administration of the influenza vaccine is the main strategy to prevent influenza in immunocompromised patients. Here, we reviewed the recent literature regarding the clinical significance of the influenza virus infection, as well as the immunogenicity and safety of the influenza vaccine in HIV‑infected individuals, solid-organ and stem-cell transplant recipients and patients receiving biological agents. Epidemiological data produced during the 2009 influenza pandemic have confirmed that immunocompromised patients remain at high risk of influenza-associated complications, namely viral and bacterial pneumonia, hospitalization and even death. The immunogenicity of the influenza vaccine is overall reduced in immunocompromised patients, although a significant clinical protection from influenza is expected to be obtained with vaccination. Influenza vaccination is safe in immunocompromised patients. The efficacy of novel strategies to improve the immunogenicity to the vaccine, such as the use of adjuvanted vaccines, boosting doses and intradermal vaccination, needs to be validated in appropriately powered clinical trials.
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Affiliation(s)
- Delphine Zbinden
- Infectious Diseases Service, University Hospital, University of Lausanne, Lausanne, Switzerland
- Transplantation Center, University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Oriol Manuel
- Infectious Diseases Service, University Hospital, University of Lausanne, Lausanne, Switzerland
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Azevedo L, Gerhard J, Miraglia J, Precioso A, Tavares Timenetsky M, Agena F, Gamba C, Shikanai Yasuda M, David-Neto E, Pierrotti L. Seroconversion of 2009 pandemic influenza A (H1N1) vaccination in kidney transplant patients and the influence of different risk factors. Transpl Infect Dis 2013; 15:612-8. [DOI: 10.1111/tid.12140] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 11/07/2012] [Accepted: 04/21/2013] [Indexed: 01/02/2023]
Affiliation(s)
- L.S. Azevedo
- Renal Transplantation Service; Hospital das Clínicas - University of São Paulo Medical School; São Paulo Brazil
| | - J. Gerhard
- Division of Infectious Diseases; Hospital das Clínicas - University of São Paulo Medical School; São Paulo Brazil
| | - J.L. Miraglia
- Division of Clinical Trials and Pharmacovigilance; Instituto Butantan; São Paulo Brazil
| | - A.R. Precioso
- Division of Clinical Trials and Pharmacovigilance; Instituto Butantan; São Paulo Brazil
| | | | - F. Agena
- Renal Transplantation Service; Hospital das Clínicas - University of São Paulo Medical School; São Paulo Brazil
| | - C. Gamba
- Division of Infectious Diseases; Hospital das Clínicas - University of São Paulo Medical School; São Paulo Brazil
| | - M.A. Shikanai Yasuda
- Division of Infectious Diseases; Hospital das Clínicas - University of São Paulo Medical School; São Paulo Brazil
| | - E. David-Neto
- Renal Transplantation Service; Hospital das Clínicas - University of São Paulo Medical School; São Paulo Brazil
| | - L. Pierrotti
- Division of Infectious Diseases; Hospital das Clínicas - University of São Paulo Medical School; São Paulo Brazil
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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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38
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Impact of anti-T-cell therapy in the immunogenicity of seasonal influenza vaccine in kidney transplant recipients. Transplantation 2012; 94:630-6. [PMID: 22895612 DOI: 10.1097/tp.0b013e31825f7f82] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The influence of anti-T-cell therapy in the immunogenicity of the influenza vaccine in kidney transplant recipients remains unclear. METHODS During the 2010 to 2011 influenza season, we evaluated the immune response to the inactivated trivalent influenza vaccine in kidney transplant recipients having received Thymoglobulin or basiliximab as induction therapy. A hemagglutination inhibition assay was used to assess the immunogenicity of the vaccine. The primary outcome was geometric mean titers of hemagglutination inhibition after influenza vaccination. RESULTS Sixty patients (Thymoglobulin n=22 and basiliximab n=38) were included. Patients in the Thymoglobulin group were older (P=0.16), showed higher creatinine levels (P=0.16) and had more frequently received a previous transplant (P=0.02). There were no significant differences in geometric mean titers for any of the three viral strains between groups (P=0.69 for H1N1, P=0.56 for H3N2, and P=0.7 for B strain). Seroconversion to at least one viral strain was seen in 15 (68%) of 22 patients in the Thymoglobulin group and 28 (73%) of 38 in the basiliximab group (P=0.77). In patients vaccinated during the first year after receiving anti-T-cell therapy (n=25), there was a trend toward lower vaccine responses in the Thymoglobulin group. Patients who received Thymoglobulin showed lower CD4(+) cell counts and lower levels of IgM, at an average of 16.2 months after transplantation. A multivariate analysis showed that only the absence of mycophenolate was associated with a better vaccine response (odds ratio=9.47; 95% confidence interval, 1.03-86.9; P=0.047). CONCLUSION No significant differences were seen in immunogenicity of the influenza vaccine in kidney transplant recipients having received either Thymoglobulin or basiliximab.
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Le Corre N, Thibault F, Noble CP, Meiffrédy V, Daoud S, Cahen R, Charreau I, Bottigioli D, Dollinger C, Aboulker JP, Autran B, Morelon E, Barrou B. Effect of two injections of non-adjuvanted influenza A H1N1pdm2009 vaccine in renal transplant recipients: INSERM C09-32 TRANSFLUVAC trial. Vaccine 2012; 30:7522-8. [DOI: 10.1016/j.vaccine.2012.10.047] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 10/03/2012] [Accepted: 10/13/2012] [Indexed: 11/25/2022]
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Fairhead T, Hendren E, Tinckam K, Rose C, Sherlock CH, Shi L, Crowcroft NS, Gubbay JB, Landsberg D, Knoll G, Gill J, Kumar D. Poor seroprotection but allosensitization after adjuvanted pandemic influenza H1N1 vaccine in kidney transplant recipients. Transpl Infect Dis 2012; 14:575-83. [PMID: 22999005 DOI: 10.1111/tid.12006] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 04/20/2012] [Accepted: 07/04/2012] [Indexed: 01/05/2023]
Abstract
BACKGROUND Seasonal and pandemic influenza virus infections in renal transplant patients are associated with poor outcomes. During the pandemic of 2009-2010, the AS03-adjuvanted monovalent H1N1 influenza vaccine was recommended for transplant recipients, although its immunogenicity in this population was unknown. We sought to determine the safety and immunogenicity of an adjuvant-containing vaccine against pandemic influenza A H1N1 2009 (pH1N1) administered to kidney transplant recipients. METHODS We prospectively enrolled 124 adult kidney transplant recipients in the fall of 2009 at two transplant centers. Cohort 1 (n = 42) was assessed before and after pH1N1 immunization, while Cohort 2 (n = 82) was only assessed post immunization. Humoral response was measured by the hemagglutination inhibition assay. Vaccine safety was assessed by adverse event reporting, graft function, and human leukocyte antigen (HLA) alloantibody measurements. RESULTS Cohort 1 had a low rate of baseline seroprotection to pH1N1 (7%) and a low rate of seroprotection after immunization (31%). No patient <6 months post transplant (n = 5) achieved seroprotection. Seroprotection rate was greater in patients receiving double as compared with triple immunosuppression (80% vs. 24%, P = 0.01). In Cohort 2, post-immunization seroprotection was 35%. In both cohorts, no confirmed cases of pH1N1 infection occurred. No difference was seen in estimated glomerular filtration rate before (54.3 mL/min/1.73 m(2) ) and after (53.8 mL/min/1.73 m(2) ) immunization, and no acute rejections had occurred after immunization at last follow-up. In Cohort 1, 11.9% of patients developed new anti-HLA antibodies. CONCLUSION An adjuvant-containing vaccine to pH1N1 provided poor seroprotection in renal transplant recipients. Receiving triple immunosuppression was associated with a poor seroresponse. Vaccination appeared safe, but some patients developed new anti-HLA antibodies post vaccination. Alternative strategies to improve vaccine responses are necessary.
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Affiliation(s)
- T Fairhead
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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Birdwell KA, Ikizler MR, Wang L, Byrne DW, Sannella EC, Wright PF, Ikizler TA. Seasonal maintenance of influenza vaccine-induced antibody response in kidney transplant recipients. Am J Nephrol 2012; 36:201-7. [PMID: 22906930 DOI: 10.1159/000341653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 07/03/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Although annual influenza vaccination is recommended for kidney transplant recipients, efficacy as reflected by serum antibody titers has not been well studied beyond 1 month in kidney transplant recipients. METHODS We performed a single-center prospective cohort study of 51 kidney transplant recipients and 102 healthy controls receiving the 2006-2007 influenza vaccine. Anti-hemagglutinin antibody titers to A/H1N1, A/H3N2, and B were measured before and 1 month after vaccination, and again at the end of influenza season. The primary outcome was the proportion of participants maintaining seroprotection (antibody titer ≥1:32) for the duration of the influenza season after influenza vaccination. RESULTS Median follow-up time was 175 and 155 days in the transplant and control groups, respectively. For types A/H1N1 and B, a similar high proportion of the transplant and control groups (88.5 and 81.6% vs. 83.7 and 74.2% for A/H1N1 and B, respectively) maintained seroprotection. For type A/H3N2, significantly less of the transplant group (66.7%) versus the control group (90%) maintained a protective influenza vaccine response (odds ratio 0.21, 95% confidence interval 0.07-0.64). This difference disappeared in adjusted analyses. Actual geometric mean titers decreased significantly within both groups (p < 0.001) but this did not differ between groups. CONCLUSIONS Once they have developed protective vaccine-induced antibody responses to influenza vaccine, kidney transplant recipients are able to maintain adequate protective levels of antibody compared with healthy controls.
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Affiliation(s)
- Kelly A Birdwell
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Mycophenolate and lower graft function reduce the seroresponse of kidney transplant recipients to pandemic H1N1 vaccination. Kidney Int 2012; 82:212-9. [PMID: 22495292 DOI: 10.1038/ki.2012.106] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In late 2009 transplant organizations recommended that kidney recipients be vaccinated for pandemic H1N1 influenza (pH1N1); however, the vaccine efficacy was unknown. We had offered a monovalent non-adjuvanted pH1N1 vaccine to transplant recipients. Here we compared the pre- and post-vaccination seroresponses of 151 transplant recipients to that of 71 hemodialysis patients and 30 healthy controls. Baseline seroprotection was similar between groups but was significantly different at 1 month (44, 56, and 87%, respectively). Seroconversion was significantly less common for transplant recipients (32%) than dialysis patients (45%) and healthy controls (77%). After adjusting for age and gender, dialysis patients were significantly more likely (2.7-fold) to achieve new seroprotection than transplant recipients. The likelihood of seroprotection in transplant recipients was significantly reduced by mycophenolate use (adjusted odds ratio 0.24), in a dose-dependent manner, and by reduced eGFR (adjusted odds ratio 0.16 for worst to best). Seroprotection and geometric mean antibody titers increased substantially in 49 transplant recipients who subsequently received the 2010 seasonal influenza vaccine. Thus, patients requiring renal replacement therapy had reduced seroresponses to vaccination with the monovalent vaccine compared with healthy controls. Transplant recipient responses were further reduced if they were receiving mycophenolate or had significantly lower graft function.
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Meggitt SJ, Anstey AV, Mohd Mustapa MF, Reynolds NJ, Wakelin S. British Association of Dermatologists' guidelines for the safe and effective prescribing of azathioprine 2011. Br J Dermatol 2012; 165:711-34. [PMID: 21950502 DOI: 10.1111/j.1365-2133.2011.10575.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- S J Meggitt
- Department of Dermatology, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK.
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Beck CR, McKenzie BC, Hashim AB, Harris RC, Zanuzdana A, Agboado G, Orton E, Béchard-Evans L, Morgan G, Stevenson C, Weston R, Mukaigawara M, Enstone J, Augustine G, Butt M, Kim S, Puleston R, Dabke G, Howard R, O'Boyle J, O'Brien M, Ahyow L, Denness H, Farmer S, Figureroa J, Fisher P, Greaves F, Haroon M, Haroon S, Hird C, Isba R, Ishola DA, Kerac M, Parish V, Roberts J, Rosser J, Theaker S, Wallace D, Wigglesworth N, Lingard L, Vinogradova Y, Horiuchi H, Peñalver J, Nguyen-Van-Tam JS. Influenza vaccination for immunocompromised patients: systematic review and meta-analysis from a public health policy perspective. PLoS One 2011; 6:e29249. [PMID: 22216224 PMCID: PMC3245259 DOI: 10.1371/journal.pone.0029249] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 11/23/2011] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Immunocompromised patients are vulnerable to severe or complicated influenza infection. Vaccination is widely recommended for this group. This systematic review and meta-analysis assesses influenza vaccination for immunocompromised patients in terms of preventing influenza-like illness and laboratory confirmed influenza, serological response and adverse events. METHODOLOGY/PRINCIPAL FINDINGS Electronic databases and grey literature were searched and records were screened against eligibility criteria. Data extraction and risk of bias assessments were performed in duplicate. Results were synthesised narratively and meta-analyses were conducted where feasible. Heterogeneity was assessed using I(2) and publication bias was assessed using Begg's funnel plot and Egger's regression test. Many of the 209 eligible studies included an unclear or high risk of bias. Meta-analyses showed a significant effect of preventing influenza-like illness (odds ratio [OR]=0.23; 95% confidence interval [CI]=0.16-0.34; p<0.001) and laboratory confirmed influenza infection (OR=0.15; 95% CI=0.03-0.63; p=0.01) through vaccinating immunocompromised patie nts compared to placebo or unvaccinated controls. We found no difference in the odds of influenza-like illness compared to vaccinated immunocompetent controls. The pooled odds of seroconversion were lower in vaccinated patients compared to immunocompetent controls for seasonal influenza A(H1N1), A(H3N2) and B. A similar trend was identified for seroprotection. Meta-analyses of seroconversion showed higher odds in vaccinated patients compared to placebo or unvaccinated controls, although this reached significance for influenza B only. Publication bias was not detected and narrative synthesis supported our findings. No consistent evidence of safety concerns was identified. CONCLUSIONS/SIGNIFICANCE Infection prevention and control strategies should recommend vaccinating immunocompromised patients. Potential for bias and confounding and the presence of heterogeneity mean the evidence reviewed is generally weak, although the directions of effects are consistent. Areas for further research are identified.
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Affiliation(s)
- Charles R Beck
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom.
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Felldin M, Studahl M, Svennerholm B, Friman V. The antibody response to pandemic H1N1 2009 influenza vaccine in adult organ transplant patients. Transpl Int 2011; 25:166-71. [DOI: 10.1111/j.1432-2277.2011.01391.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kumar D, Blumberg EA, Danziger-Isakov L, Kotton CN, Halasa NB, Ison MG, Avery RK, Green M, Allen UD, Edwards KM, Miller G, Michaels MG. Influenza vaccination in the organ transplant recipient: review and summary recommendations. Am J Transplant 2011; 11:2020-30. [PMID: 21957936 DOI: 10.1111/j.1600-6143.2011.03753.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Influenza virus causes a spectrum of illness in transplant recipients with a high rate of lower respiratory disease. Seasonal influenza vaccination is an important public health measure recommended for transplant recipients and their close contacts. Vaccine has been shown to be safe and generally well tolerated in both adult and pediatric transplant recipients. However, responses to vaccine are variable and are dependent on various factors including time from transplantation and specific immunosuppressive medication. Seasonal influenza vaccine has demonstrated safety and no conclusive evidence exists for a link between vaccination and allograft dysfunction. Annually updated trivalent inactivated influenza vaccines have been available and routinely used for several decades, although newer influenza vaccination formulations including high-dose vaccine, adjuvanted vaccine, quadrivalent inactivated vaccine and vaccine by intradermal delivery system are now available or will be available in the near future. Safety and immunogenicity data of these new formulations in transplant recipients requires investigation. In this document, we review the current state of knowledge on influenza vaccines in transplant recipients and make recommendations on the use of vaccine in both adult and pediatric organ transplant recipients.
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Affiliation(s)
- D Kumar
- Transplant Infectious Diseases, University of Alberta, Edmonton, AB, Canada Division of Infectious Diseases, University of Pennsylvania, Philadelphia, PA, USA.
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Antón A, Pumarola T. Influenza in immunocompromised patients: considerations for therapy. Future Virol 2011. [DOI: 10.2217/fvl.11.61] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Influenza infection results in substantial morbidity and mortality in immunocompromised patients, and the risks for influenza and its related complications depend on the degree of immunosuppression. In addition to influenza vaccination and infection control precautions, two classes of antiviral drugs are currently approved for treatment and prophylaxis in uncomplicated infected patients. However, there are no randomized controlled trials assessing the efficacy and safety of licensed antivirals for influenza management in immunocompromised patients. The purpose of this article is to highlight some considerations for therapy in immunocompromised patients, the usefulness of vaccination for the prevention of influenza and the clinical interest in surveillance of antiviral resistance.
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Affiliation(s)
| | - Tomás Pumarola
- Virology Section, Department of Microbiology, Barcelona Centre for International Health Research (CRESIB, Hospital Clínic – Universitat de Barcelona), 08036 Barcelona, Spain
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Esposito S, Meregalli E, Daleno C, Ghio L, Tagliabue C, Valzano A, Serra D, Galeone C, Edefonti A, Principi N. An open-label, randomized clinical trial assessing immunogenicity, safety and tolerability of pandemic influenza A/H1N1 MF59-adjuvanted vaccine administered sequentially or simultaneously with seasonal virosomal-adjuvanted influenza vaccine to paediatric kidney transplant recipients. Nephrol Dial Transplant 2011; 26:2018-24. [PMID: 20974645 PMCID: PMC7313880 DOI: 10.1093/ndt/gfq657] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 09/19/2010] [Accepted: 10/01/2010] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate the immunogenicity, safety and tolerability of the 2009 A/H1N1 MF59-adjuvanted influenza vaccine, administered sequentially or simultaneously with the seasonal 2009-10 virosomal-adjuvanted influenza vaccine, to paediatric kidney transplant recipients. METHODS Thirty-two children and adolescents with transplanted kidneys and 32 age- and gender-matched healthy controls were randomized 1:1 to receive the pandemic vaccine upon enrolment and the seasonal vaccine 1 month later (16 transplant recipients and 16 healthy controls), or to receive the two vaccines simultaneously upon enrolment (16 transplant recipients and 16 healthy controls). RESULTS When the pandemic vaccine was administered sequentially to the seasonal vaccine, it was significantly less immunogenic in the patients than in the controls (P < 0.05); when it was administered together with the seasonal vaccine, the immune response of both patients (P < 0.05) and controls (P < 0.05) was significantly greater than when it was administered sequentially. Seroconversion rates and the geometric mean titres of all of the seasonal antigens were significantly lower in the patients, regardless of the type of vaccine administration (P < 0.05). Simultaneous administration was associated with a better immune response against A/H1N1 and A/H3N2 antigens in both patients and controls, and did not increase the mild local and systemic reactions. No impact on renal function was observed. CONCLUSIONS Paediatric kidney transplant recipients have a lower immune response to the pandemic influenza A/H1N1 MF59-adjuvanted and seasonal virosomal-adjuvanted influenza vaccines than healthy controls. The simultaneous administration of the two vaccines seems to increase immune response to both pandemic and seasonal A/H1N1 and A/H3N2 antigens, and has the same safety profile as that of the pandemic vaccine administered sequentially to the seasonal vaccine.
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Affiliation(s)
- Susanna Esposito
- Department of Maternal and Pediatric Sciences, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Meregalli
- Pediatric Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Cristina Daleno
- Department of Maternal and Pediatric Sciences, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luciana Ghio
- Pediatric Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Tagliabue
- Department of Maternal and Pediatric Sciences, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonia Valzano
- Department of Maternal and Pediatric Sciences, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Domenico Serra
- Department of Maternal and Pediatric Sciences, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlotta Galeone
- Department of Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
- Department of Occupational Health “Clinica del Lavoro Luigi Devoto”, Section of Medical Statistics “Giulio A. Maccacaro”, Università degli Studi di Milano, Milan, Italy
| | - Alberto Edefonti
- Pediatric Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Brakemeier S, Schweiger B, Lachmann N, Glander P, Schonemann C, Diekmann F, Neumayer HH, Budde K. Immune response to an adjuvanted influenza A H1N1 vaccine (Pandemrix(R)) in renal transplant recipients. Nephrol Dial Transplant 2011; 27:423-8. [DOI: 10.1093/ndt/gfr278] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
The number of patients with impaired immune response has been steadily increasing within the last years, not only with the onset of the AIDS epidemic, but also due to increasing numbers of subjects on immunosuppressive therapies. These patients are at an increased risk for infections, many of which are preventable by immunization. Inactivated vaccines are generally safe in subjects with underlying immunosuppression. However, immune response and protection may be hampered, depending on the extent of immunosuppression. In contrast, live vaccines such as yellow fever, measles, rubella, herpes zoster, and cholera may lead to severe reactions in immunocompromised patients and have been shown to deteriorate some immune-mediated diseases such as multiple sclerosis. Data on the efficacy of vaccines in biological therapies is scarce. Where necessary vaccines should be updated before immunosuppressive therapies are started. To improve the vaccination status several guidelines exist for immunosuppressed patients at risk such as those with rheumatic diseases, asplenia or solid organ and hematopoietic stem cell transplantation.
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