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

Abstract

Background: Historically, the IDSA and the AST have recommended that live vaccines not be administered post-transplant due to concern for induction of vaccinestrain disease in immunocompromised hosts. However, recent prospective studies and revised AST guidelines published in April 2019 suggest that in the current era of immunosuppression minimization, live vaccines may be safely administered to select transplant recipients with resulting immunoprotection. The goal of this study was to assess current post-transplant live vaccine practices at individual pediatric liver transplant centers following the updated AST guidelines. Methods: A six-item email survey detailing center-specific post-transplant live vaccine practices followed by up to three response-specific questions were distributed between July 2019 and May 2020 to a representative from each center participating in the SPLIT consortium. Results: The overall survey response rate was 93% (41/44 centers). Only 29% (12/41) of centers offer live vaccines post-transplant; each of these 12 centers uses different eligibility criteria for live vaccines. There was no difference between large (ten or more transplants per year) and small (less than ten transplants per year) centers in likelihood to offer live vaccines post-transplant. The main reasons for a center not offering post-transplant live vaccines were safety concerns and inability to reach group consensus. Conclusions: The majority of pediatric liver transplant centers are reluctant to offer live vaccines post-transplant despite the updated AST guidelines. Prospective multicenter studies are needed to confirm safety and immunogenicity of live vaccines post-transplant.

Quality improvement project to improve vaccinations in the pediatric liver transplant population

“…This guideline discussed measles, mumps, rubella and varicella vaccines in the posttransplant population and acknowledged that several small studies show promising results of vaccine efficacy and safety; however, the recommendation from the society in 2019 is that "vaccination should be performed only in select patients with appropriate education and close follow-up." 14 The Transplantation Society also performed a review regarding vaccine recommendations in the solid organ transplant population and came to a similar conclusion as the AST Infectious Disease Community of Practice: measles, mumps, rubella, and varicella vaccination in the post-transplant population has been administered safely in patients on low-dose immunosuppression based on the studies performed by Chaves et al, 15 Kawano et al 9 and Posfay-Barbe et al 16,17 A recent study by Kemme et al 18 surveyed 41 Society of Pediatric Liver Transplant centers and found only 29% were offering live vaccines, all of which have different eligibility criteria for live vaccines.…”

“…A recent study by Kemme et al 18 surveyed 41 Society of Pediatric Liver Transplant centers and found only 29% were offering live vaccines, all of which have different eligibility criteria for live vaccines. Another survey by Pettet et al 19 was given in 2019 to the International Pediatric Transplantation Association listserv and discovered that management of live vaccines in solid organ transplant recipients is “not optimal and requires further education.” In addition, transplant recipients are generally underimmunized with all vaccines 20 .…”

Live Vaccines in Pediatric Liver Transplant Recipients: “To Give or Not to Give”

“…A recent survey of Society of Pediatric Liver Transplantation (SPLIT) centers demonstrated that only 29% of pediatric LT centers currently recommend live vaccines posttransplant. 30 Reasons for not recommending LAVs posttransplant included concerns about vaccine safety (90% of centers), concerns about vaccine efficacy (28% of centers), inability to reach consensus among transplant providers at their center (34% of centers), no capacity to give live vaccines in transplant clinic (14% of centers), and/or prior history of adverse events with administration of live vaccines posttransplant (7% of centers). 30 Likewise, in a recent survey of members of the International Pediatric Transplantation Association, only 57% of respondents believe that LAVs should be administered posttransplant, and only 21% have actually administered LAVs to one of their transplant recipients.…”

Live virus vaccination following pediatric liver transplantation: Outcomes from two academic children’s hospitals

“…Studies show, however, that many pediatric LT providers remain hesitant to vaccinate with live virus vaccines post‐transplant, often citing concern for rejection and vaccine‐associated viral reactivation 16 . A 2020 survey of Society of Pediatric Liver Transplantation (SPLIT) centers found that only 29% of centers currently administer LVV post‐transplant 17 …”

“…16 A 2020 survey of Society of Pediatric Liver Transplantation (SPLIT) centers found that only 29% of centers currently administer LVV post-transplant. 17 Our two large, quaternary care pediatric centers have routinely provided LVV after LT to select patients for over 20 years. We retrospectively reviewed our experience with LVV after LT to evaluate the safety of live virus vaccines and the characteristics of the recipient population that are associated with successful LVV post-transplant.…”