Vaccinations in Paediatric Solid Organ Transplant Candidates and Recipients
Abstract
:1. Introduction—General Indications
- Lack of previous immunity from natural infection exposure;
- Incomplete immunization schedule at the time of transplantation;
- Incomplete or inadequate response to vaccines due to the post-transplant immunosuppressive treatment;
- Progressive waning of the protective antibody titre, occurring after transplantation [3].
- Children who received transplants when younger than two years;
- Transplant recipients of lung, intestine, heart and multivisceral organs.
- The complex primary medical problems, with frequent hospitalizations and insufficient opportunities, for which a child is considered well enough to proceed with immunizations;
- The fact that primary care practitioners sometimes consider the patient’s underlying chronic condition as a contraindication for immunization;
- The sub-optimal antibody responses in chronic liver and renal diseases;
- 47% of patients had all recommended doses for their age of the 6-fold vaccine (containing DTaP, HBV, poliomyelitis and HiB), plus their Streptococcus pneumoniae conjugate vaccine and the MMR vaccine.
- 30% of children had partially complete vaccination status (lack of the 2nd dose of MMR);
- World Health Organization (WHO): https://www.who.int/teams/immunization-vaccines-and-biologicals/policies/who-recommendations-for-routine-immunization---summary-tables (accessed on 20 July 2024).
- Centre for Disease Control and Prevention (CDC): https://www.cdc.gov/vaccines/ (accessed on 20 July 2024).
- The European Centre for Disease Prevention and Control (ECDC), providing country specific vaccination recommendations: https://vaccine-schedule.ecdc.europa.eu/ (accessed on 20 July 2024)
- The possibility that the viral-strain pathogen can cause a severe or life-threatening infection in an immunocompromised patient;
- The possibility that patients cannot mount an adequate and protective immune response, due to the immunosuppressive treatment.
1.1. Vaccination in Healthcare Workers and Close Contacts
- All the inactivated vaccines;
- Vaccination against influenza yearly, preferably with inactivated vaccine (IIV).
- Most of the live vaccines: MMR, varicella, Rotavirus (if infants are aged 2–7 months).
1.2. Travel Vaccinations
2. Methods
3. Inactivated-Recombinant Vaccinations: Pre- and Post-Transplant Indications
3.1. Tetanus and Diphtheria
3.2. Pertussis
3.3. Poliomyelitis
3.4. Haemophilus Influenzae Type B (HiB)
3.5. Hepatitis A
3.6. Hepatitis B
- Non-responder subjects (showing anti-HBsAg < 10 IU/L) require a new course of vaccination;
- Responder subjects need a re-assessment of antibody concentrations every 12 months. If HBsAg titres drop below 10 IU/L, a booster immunization dose should be administered [7].
3.7. Meningococcal Vaccine
3.8. Pneumococcal Vaccine
- Children less than 2 years of age should receive a 13-valent conjugated vaccine.
- Children from 2 to 5 years of age should undergo the following schedule: two doses of PCV13, second dose > 8 weeks after the first one; in addition, children who are transplant candidates should receive PPV23 at least 8 weeks after completing PCV13 schedule.
3.9. HPV Vaccine
3.10. Influenza
3.11. COVID-19
4. Live Vaccinations: Pre- and Post-Transplant Indications
4.1. Measles, Mumps, Rubella and Varicella
- Renal and liver transplant, more than one year post-transplant, 2–6 months post-episode of acute rejection, AND “minimum immune suppression” AND “minimum immune criteria”.
- The “minimum immune criteria” are defined as follows: absolute lymphocyte count >1500 (children ≤ 6 yo), or >1000 (children > 6 yo) cells/μL, CD4 > 700 (children ≤ 6 yo) or >500 (children > 6 yo), cells/μL; normal IgG levels; consider the ability to produce protective antibodies to inactivated vaccines prior to administration of live viral vaccines.
- The “minimum immune suppression” is defined as follows: steroid < 2 mg/kg/day or total cumulative < 20 mg/day, tacrolimus < 8 ng/mL or cyclosporine < 100 ng/mL.
- Patients who are receiving mycophenolate mofetil (MMF);
- Patients who have received T-cell depleting agents (for ATG wait 12 months, for Alemtuzumab wait 24 months);
- Patients who have received Rituximab (wait at least 12 months);
- Patients with persistently elevated Epstein Barr Virus (EBV) viral load;
- Patients who underwent total timectomy;
4.2. Rotavirus
5. Discussion and Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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Type of Vaccine | Minimum Age at First Dose | Standard Schedule | Accelerated Schedule | Recommended after Transplant |
---|---|---|---|---|
Inactivated Vaccines | ||||
Diphtheria/Tetanus/Pertussis | 6 weeks | WHO schedule: - The primary series includes 3 doses (with interval between doses: 4–8 weeks) 3 booster doses are administered as follows: - At 12–23 months DTP-containing vaccine; - At 4–7 years only Td-containing vaccine; - At 9–15 yrs only Td-containing vaccine. CDC schedule: 5-dose series are administered at ages 2, 4, 6, 15–18 months, 4–6 years. | The minimum interval between 1st and 2nd dose: 4 weeks; between 2nd and 3rd dose: 4 weeks; between 3rd and 4th dose: 6 months and after age of 12 months; between 4th and 5th dose: 6 months and after age of 4 yo. | Yes |
Inactivated Polio (IPV, applied to countries in polio-free regions with a very low risk of importation and sustained high routine immunization coverage) | 6 weeks | WHO schedule: The primary series includes 3 doses (with interval between doses: 4–8 weeks); an IPV booster (6 months after 3rd dose) is needed when 1st dose is given at <8 weeks. CDC schedule: 4-dose series are administered at age 2 months, 4 months, 6 through 18 months, 4 through 6 years. | Minimum interval between 1st and 2nd dose: 4 weeks; between 2nd and 3rd dose: 4 weeks and after age of 6 months; between 3rd and 4th dose: 6 months and after age of 4 yo. | Yes |
Haemophilus Influenzae B (HiB) | 6 weeks | WHO schedule includes 3 options: 3 primary doses without a booster OR 2 primary doses plus a booster OR 3 primary doses with a booster Interval between doses: 4 weeks in case where 3 primary doses are given; 8 weeks in case where 2 primary doses are given. Booster doses: at least six months after completion of the primary series. Single dose if >12 months of age. Not recommended for children > 5 yrs. CDC schedule: 4-dose series, including 3-dose primary series at age 2, 4 and 6 months, followed by a booster dose at age 12–15 months OR 3-dose series, including 2-dose primary series at age 2 and 4 months, followed by a booster dose at age 12–15 months. | Minimum interval between 1st and 2nd dose: 4 weeks; between 2nd and 3rd dose: 4 weeks; between 3rd and 4th dose: 8 weeks and after age of 12 months. | Yes |
HBV | At birth | WHO schedule includes 2 options: 3-doses schedule, with first dose given at birth and second and third doses given at the same time as the first and third doses of DTP-containing vaccine; OR 4-doses schedule, where a monovalent birth dose is followed by 3 doses, usually given with other routine infant vaccines. The interval between doses should be at least 4 weeks. CDC schedule: 3-dose series at age 0, 1–2, 6–18 months. Infants who did not receive a birth dose should begin the series as soon as possible; in this case: dose interval 1st–2nd dose: 4 weeks; dose interval 2nd–3rd dose: 8 weeks and at least 16 weeks after first dose. Minimum age for the final dose: 24 weeks. | Minimum interval between 1st and 2nd dose: 4 weeks; between 2nd and 3rd dose: 8 weeks and after 24 weeks of age. | Yes |
HAV | ≥12 months | WHO schedule: 1 or 2 doses; interval between 1st and 2nd dose: 6–18 months (max around 4–5 years) CDC schedule: 2-dose series at age 12–23 months (minimum interval: 6 months) | Minimum interval between 1st and 2nd dose: 4 weeks. | Yes |
HPV | 9 years | WHO schedule: 1–2 doses in girls at 9–14 yo; Interval between doses: 6–12 months. CDC schedule: 2- or 3-dose series, depending on the age at first vaccination: Age 9–14 years: 2-dose series at 0, 6–12 months (minimum interval: 5 months). Age 15 years or older: 3-dose series at 0, 1–2 months, 6 months. | Minimum interval between 1st and 2nd dose: 4 weeks; between 2nd and 3rd dose: 12 weeks. | Yes |
MENACVY | 2-9-23 months (according to different vaccine formulations) | WHO schedule: One single dose to individuals ≥2 years. It is also approved for children 9–23 months of age and given as a 2-dose series, 3 months apart, beginning at the age of 9 months. CDC schedule: 2-dose series at age 11–12 years and 16 years. Only in particular conditions (functional asplenia, HIV infection, persistent complement component deficiency), different schedules, starting from 2 months of age. | First dose at 9 months; interval between 1st and 2nd dose: 12 weeks. | Yes |
MENB | 3 months | WHO schedule: This vaccine is not included. CDC schedule: Adolescents 16–18 yo: 2-dose series, at least 1–6 months (according to different vaccine formulations) In some European Countries: 2-dose series at 3–5 months of age, followed by a booster dose at 15 months of age. Minimum interval between 1st and 2nd dose: 2 months. Minimum interval between 2nd dose and booster: 6 months. | / | Yes |
Pneumococcal disease | 6 weeks | WHO schedule: PCV 13 vaccine, including 2 options: - 2 primary doses at an interval of ≥8 week, followed by a booster dose at 9–18 months of age. - 3 doses, each 4 weeks apart. CDC schedule: 4-dose series at 2, 4, 6, 12–15 months (PCV13 or PCV 15) For PPV23 indications: see text. | Minimum interval between 1st and 2nd dose: 4 weeks; between 2nd and 3rd dose: 4 weeks; between 3rd and 4th: 8 weeks. If between 12 and 24 months and unvaccinated: give 3 doses, 8 weeks apart; If between 24 months and 5 yo and unvaccinated, give 1 dose. | Yes (see text for details) |
SARS-CoV-2 | 6 months | WHO schedule: Not included (different approach in different countries, according to vaccine availability) CDC schedule: Age 6 months–4/5 years: 2-dose series at 0, 4–8 weeks (bivalent Moderna, 0.25 mL/0.25 ug) OR 3-dose series at 0, 3–8 weeks, 8 weeks (2 months) after dose 2 (bivalent Pfizer-BioNTech, 0.2 mL/0.3 ug); Age > 5 years: 1 dose bivalent Moderna (6–11 yo dose 0.25 mL/25 ug; ≥12 yo dose 0.5 mL/50 ug) OR 1 dose bivalent Pfizer-BioNTech (age 5–11 yo dose 0.2 mL/10 ug; age ≥ 12 yo dose 0.3 mL/30 ug) In adolescents ≥12: Novavax 2-dose primary series (separated by at least 3–8 weeks) | / | CDC schedule for immunocompromised persons (such as transplant recipients): Age 6 months–4 years: 3-dose series at 0, 4, 8 weeks (Moderna) OR 3-dose series at 0, 3, 11 weeks (Pfizer-BioNTech); Age 5–11 years: 3-dose series at 0, 4, 8 weeks (Moderna) OR 3-dose series at 0, 3, 7 weeks (Pfizer-BioNTech) Age 12–18 years: 3-dose series at 0, 4, 8 weeks (Moderna) OR 2-dose series at 0, 3 weeks (Novavax) OR 3-dose series at 0, 3, 7 weeks (Pfizer-BioNTech) Booster dose: 1 more dose at least 2 months following the last recommended dose. |
Influenza inactivated vaccine (inactivated tri- and quadrivalent) | 6 months | WHO and CDC schedule: 6 mo–8 yo: 2 doses, 4 weeks interval between doses. ≥9 years: 1 dose. Revaccinate annually: 1 dose only. | Interval between 1st and 2nd dose: 4 weeks. | Yes |
LIVE vaccines | ||||
MMR (Measles/Mumps/Rubella) | 9–12 months (WHO) 12 months (CDC) | WHO schedule: 2 doses, interval between doses: 4 weeks (min) CDC schedule: 2-dose series at age 12–15 months, 4–6 years | Anticipate 1st dose at 6 months; interval between 1st and 2nd dose: 4 weeks. | Only in selected cases (see text) |
VZV | 12–18 months | WHO schedule: 1–2 doses; interval between 1st and 2nd dose from 4 weeks to 3 months, according to manufacturer recommendations CDC schedule: 2-dose series at age 12–15 months, 4–6 years. Dose 2 may be administered as early as 3 months after dose 1. | Anticipate 1st dose at 6 months; interval between 1st and 2nd dose: 4 weeks. | Only in selected cases (see text) |
Rotavirus | 6 weeks | WHO schedule: 2–3-dose series (depending on product); interval between doses: 4 weeks (min) Vaccination of children >24 months of age is not recommended. CDC schedule: 2-dose series at age 2 and 4 months OR 3-dose series at age 2, 4 and 6 months (depending on product). maximum age for the final dose: 8 months | Minimum age: 6 weeks. Interval between 1st and 2nd dose: 4 weeks. Interval between 2nd and 3rd dose: 4 weeks. | No |
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Casotti, V.; Stroppa, P.; Bravi, M.; Tebaldi, A.; Loglio, A.; Viganò, M.; Fagiuoli, S.; D’Antiga, L. Vaccinations in Paediatric Solid Organ Transplant Candidates and Recipients. Vaccines 2024, 12, 952. https://doi.org/10.3390/vaccines12090952
Casotti V, Stroppa P, Bravi M, Tebaldi A, Loglio A, Viganò M, Fagiuoli S, D’Antiga L. Vaccinations in Paediatric Solid Organ Transplant Candidates and Recipients. Vaccines. 2024; 12(9):952. https://doi.org/10.3390/vaccines12090952
Chicago/Turabian StyleCasotti, Valeria, Paola Stroppa, Michela Bravi, Alessandra Tebaldi, Alessandro Loglio, Mauro Viganò, Stefano Fagiuoli, and Lorenzo D’Antiga. 2024. "Vaccinations in Paediatric Solid Organ Transplant Candidates and Recipients" Vaccines 12, no. 9: 952. https://doi.org/10.3390/vaccines12090952