Liver transplantation is established therapy for children with decompensated chronic liver disease (CLD), and in subsets of patients with acute liver failure and metabolic liver disease. [1].　Children require lifelong immuno-suppression which can predispose them to infections. The rates of immunization in pre-transplant candidates are low throughout the world. [2]. This problem gets compounded in a large country like India where the national average of children immunized under the Universal immunization program is 46% [3].

About two-thirds of all candidates referred to us for liver transplantation are partially immunized. As children with CLD cannot be transplanted for 3-4 weeks after a live vaccine is administered, it is important that early vaccination against varicella, measles, mumps and rubella, is ensured for all children who are listed for liver transplantation. Vaccination against pneumococcal disease, influenza and hepatitis A should similarly be brought forward to complete the vaccination schedule [4].

The disease burden in the post-transplant period can be reduced significantly by expediting the vaccination schedule in the pre-transplant period, and by offering immunization to household contacts. While every effort should be made to vaccinate prior to transplantation, inactivated vaccines are safe after transplantation. Live attenuated vaccines are generally contraindicated after transplantation. It is preferred that close contacts be vaccinated against measles, mumps, rubella and varicella, 4 weeks before the transplant so as to prevent the transplanted patient from having contact with wild-type viruses.

The ability to mount an immune response is impacted by the type and dose of immunosuppression [5] The effect of immunosuppression on memory T cells is incompletely understood and the life span of memory T cells has not been determined in patients who have undergone liver transplantation. However, using drugs with different modes of immunosuppressive action can have an additive effect in dampening the response to vaccination. There is no evidence to link transplant rejection to immunization.

To summarize, vaccination status should be reviewed at the time of the first visit to the treating physician and a plan should be developed. The status should be reviewed once the patient is listed for transplantation. For patients who are incompletely vaccinated prior to transplant, inactivated vaccines can be given safely once immunosuppression is established. Data on safety and immunogenicity of live vaccines in such patients is awaited.

1. Kamath BM, Olthoff KM. Liver transplantation in children: Update 2010. Pediatr Clin North Am 2010;57:401-14.

2. Verma A, Wade JJ. Immunization issues before and after solid organ transplantation in children. Pediatr Transplant. 2006;10:536-48.

3. International Institute for Population Sciences. National Family Health Survey, India 2005-2006 (NFHS-3). Mumbai: International Institute for Population Sciences; 2006.

4. Allen U, Green M. Prevention and treatment of infectious complications after solid organ transplantation in children. Pediatr Clin North Am. 2010;57:459-79.