Introduction

The adage ‘prevention is better than cure’ holds true for healthy individuals but has perhaps greater significance in transplant recipients. These individuals have impaired immunity and infection in these patients often result in excessive morbidity and mortality with antimicrobial therapy being less effective in this group compared to the unimpaired host.

South African Immunisation Schedule

In South Africa the bulk of immunisation is given in childhood as part of the Expanded Programme for Immunisation in Childhood
(EPI) (Table 1) [2]. However in the public sector, mainly due to financial constraints, a truncated schedule is used (table 2) [2].
The most recent addition to the EPI programme in the public sector has been the Haemophilus Influenza B vaccine. The measles,
mumps, and rubella (MMR) (TRIMOVAX ®) vaccine and varicella vaccine (VARILIX ®) are excluded and have to be purchased
privately. Influenza A vaccine although available is sometimes limited in stock and is excluded from the EPI as part of routine
immunisation since vaccine efficacy is dependant on the seasonal strain and costs are high.

Additional Vaccines

Other available vaccines include the meningococcal vaccine and hepatitis A vaccine and in countries where Lyme disease is common,
Lyme vaccine.

Meningococcal

The incidence of meningococcal disease after renal transplantation is unknown. There is presently no information on the efficacy
of the polysaccharide meningococcal vaccine in patients with renal disease, chronic kidney disease or kidney transplant recipients.
The Centre for Disease Control recommendations is the administration of meningococcal vaccine to patients with functional or
anatomic asplenia or travel exposure.

Hepatitis A

Presently Hepatitis A vaccine is indicated for children and adolescents in regions where the virus is endemic, all transplant
candidates with chronic liver disease, including those waiting for liver transplantation, because of the increased risk of fulminant
liver failure in these patients [4,5,6,]. No information is available in children or adults regarding the efficacy of this vaccine in
chronic kidney disease, patients on dialysis or post kidney transplant.

Lyme disease

In countries where Lyme disease is endemic, the lyme vaccine has been approved for children over 15 years and adults. Vaccine
efficacy in Lyme disease is 76% in healthy patients [7]. At present there is insufficient evidence to recommended Lyme vaccine
in post renal transplant patients.

Challenges facing transplant patients

Although immunisation appears to be an obvious way to prevent infection, transplanted patients with impaired immunity
are often unable to mount a protective immune response to active immunisation. Furthermore, immunisation with live virus
vaccines may result in unchecked proliferation of the attenuated strains. The risk of acquiring infection and the inability to
prevent infection by immunisation are directly related to the patients “net state of immunosuppression” or severity of
disease. The factors contributing to immunosuppression in these transplanted patients include the underlying disease, the
presence of allograft rejection, and the use of immunosuppressive therapy.

Another potential problem is the impact of new immunosuppressive therapies with regards to the durability of pretransplant
antibody levels and post transplant antibody response. Since this has not been investigated in a standardised manner
and the use of combination immunosuppressive regimens vary in different units, it is difficult to formulate guidelines for the
optimal use of immunisations in renal transplant recipients. Thus several of these issues remain unresolved in patients undergoing
renal transplants.

Despite the lack of evidence-based guidelines for the prevention of infections in renal transplant patients, most health care
professionals agree that these patients must remain up to date on their immunisations. Exactly when to resume immunisation
following renal transplant and how often to administer booster doses or check protective antibody levels has yet to be formalised.

Another potential concern is that patients may be transplanted shortly after receiving vaccinations, particularly live attenuated
vaccines. Such individuals are subjected to high-dose immunosuppression in the immediate post transplant period and
therefore carry a potentially high risk for unchecked proliferation of the attenuated strain. Many transplant centres withhold
immunisation until the patient is taking baseline immunosuppression and, in some, this is formalized by withholding all immunisations
during the first transplant year [8]

Recommendations

Based on the current available evidence, the following recommendations are made: (Table 3) [9]

• All children with pre-end stage and end stage renal failure receive all routine childhood immunisations and
  additional immunisation against hepatitis B, influenza, and Streptococcus pneumoniae.

• All necessary live immunisations should be administered before entry on to the transplantation waiting list
  because they are contraindicated once immunosuppressive treatment has commenced [10]

References

1. Hibberd PL, Rubin RH. Approach to immunisation in the immunosuppressive host. Infect Dis Clin North Am 1990; 4:23

2. http://198.73.159.214/avpi-rsa/ImageServlet?imageCode=2035&codeSite=AVPI_RSA

3. Centres for Disease Control. Prevention and control of meningococcal disease. Recommendations for the Advisory
   Committee on Immunisation Practices (ACIP) 2000;49(RR07):1

4. Centres for Disease Control, Prevention of Hepatitis A through active or passive immunisation: Recommendations for
   the Advisory Committee on Immunisation Practices (ACIP)1999; 48(RR12):1

5. Vento S, Garofano T, Renzini C et al. Fulminant hepatitis associated with hepatitis A virus superinfection in patients with
   chronic hepatitis C. N Engl J Med 1998;338:286.

6. Willner IR, Uhl MD, Howard SC et al. Serious hepatitis A: an analysis of patients hospitalised during an urban epidemic
   in the United States. Ann Intern Med 1998; 128:111

7. Steere AC, Sikand VK, Meurice F et al. Vaccination against Lyme disease with recombinant Borrelia burgdorferi outer-surface
   lipoprotein A with adjuvant. Lyme Disease Vaccination Study Group. N Engl J Med 1998;339:209

8. Ellis D, Gilboa N, Bellinger M, Shapiro R. Renal transplantation in infants and children. In: Renal Transplantation,
   Shapiro R, Simmons R, Simmons RL, Starzl TE (eds), Appleton and Lange, Stamford, CT, 1997.p461

9. Barbara A, Fivush MN, Alicia MN. Seminars in Nephrology Vol. 18, No 3(May), 1998, p256-263.

10. Department of Health. Immunisation against infectious disease.London:HMSO,1996

Table 1: Paediatric Vaccination Schedule in South Africa

Vaccine Type	A G E
	At Birth	6 weeks	10 weeks	14 weeks	9 months	15 months	18 months	5 years
BCG Tuberculosis
OPV Polio
DTP Diphtheria, Tetanus, Pertussis
HB Hepatitis B
Hib Haemophilus Influenza type B
Measles						* MMRMeasles, mumps, rubella		* MMR
Chicken-pox					*

* If recommended by a health care professional; † Acellular pertussis

Table 2: CHILDHOOD DISEASES IMMUNISATION SCHEDULE

BIRTH TO 5 YEARS (EPI SCHEDULE)

* BCG = Vaccine against Tubercolosis
** DPT = Diptheria, Pertusis (Whooping cough) and Tetanus (Lockjaw)
***DT = Vaccine against Diptheria and Tetanus only
EPI = Expanded Programme for Immunisation
#HiB = Haemophilus Influenza Type B

Table 3: Guidelines for Immunizing Patients With Renal Disease

* Must delay transplantation for 8 weeks following live viral vaccine.

• CRF-Chronic renal failure

• HD- haemodialysis

• PD- Peritoneal

• EPI- Expanded Programme for Immunisation in Childhood

• OPV- Oral Polio Vaccine

• MMR- Measles, mumps, rubella