The Importance of Prioritizing Pre and Posttransplant Immunizations in an Era of Vaccine Refusal and Epidemic Outbreaks

Abstract

Vaccine-preventable infections are occurring at epidemic rates both nationally and internationally. At the same time, rates of vaccine hesitancy and refusal are increasing across the country leading to decreased herd immunity. For immunosuppressed transplant recipients, this situation poses great risk. Currently, 1 in 6 pediatric solid organ transplant recipients is hospitalized with a vaccine-preventable infection in the first 5 years posttransplant. For many recipients, these infections result in significant morbidity, mortality, and increased hospitalization costs. Surprisingly, despite this risk many transplant recipients are not up-to-date on age appropriate immunizations at the time of transplant and thereafter. As a transplant community, we must prioritize immunizations in both pre and posttransplant care. Research is needed to understand how to monitor immune response to vaccines in immunosuppressed patients and when to optimally immunize patients posttransplant. Finally, recommendations about administration of live vaccines posttransplant may need to be reevaluated in the setting of measles outbreaks and decreased herd immunity.

Figure 1.

Vaccine Preventable Infections in the United States. 1A. Reported Measles Cases in the United States, Jaunuary 1- April 26, 2019. 1B. Reported Measles Cases in the United States 2000- July 3, 2019. 1C. Reported Mumps Cases in the United States, January 1- July 19, 2019. 1D. Reported Mumps Cases in the United States, 2000-June 21, 2019. Source: Morbidity and Mortality Weekly Report (MMWR), Notifiable Diseases and Mortality Tables.

Figure 2.

Annual hospitalization rates of vaccine-preventable illnesses. Shown are the percentage of the population hospitalized annually due to influenza, rotavirus, pneumococcus and respiratory syncytial virus (RSV) for the general pediatric population (yellow) and for the pediatric liver transplant population in the first year after transplant (blue). Source: Feldman AG, Beaty BL, Curtis D, Juarez-Colunga E, Kempe A. Incidence of Hospitalization for Vaccine-Preventable Infections in Children Following Solid Organ Transplant and Associated Morbidity, Mortality, and Costs. JAMA Pediatr. 2019.

Figure 3.

Immunization Schedules. Immunization Schedules according to the CDC Standard Recommended Immunization Schedule for children from birth to 18 years of age (yellow), and the accelerated immunization schedule for children awaiting transplant (purple). Values indicate the cumulative number of doses at the time points indicated. Thick outlined boxes represent immunizations included in the minimum- 7 vaccine schedule used by the National Immunization Survey. Acc, accelerated; CDC, Centers for Disease Control and Prevention; DTaP, diphtheria tetanus and pertussis vaccine; Hep A, hepatitis A vaccine; Hep B, hepatitis B vaccine; Hib, haemophilus influenzae type B vaccine; HPV, human papillomavirus vaccine; Men ACWY, meningococcal conjugate vaccine; MMR, measles mumps and rubella vaccine; mo, months; PCV13, pneumococcal conjugate vaccine; Tdap, tetanus, diphtheria and pertussis booster vaccine; yrs, years; Source: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2017; https://www.cdc.gov/vaccines/schedules/downloads/child/0–18yrs-child-combined-schedule.pdf. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2014;58(3): e44–100.