Managing

Immunosuppressant And
Vaccination In Covid Time
SPEAKER : DR. RAVI SINGH
(NEPHROLOGIST)
 Can a transplant recipient still receive the vaccine even if
they have had COVID-19 ?
• The current guidance is that everyone receives the vaccine, irrespective of past
COVID-19 infection.
• There are case reports of immunosuppressed patients developing COVID-19
reinfection, suggesting lack of appropriate immune response or waning immunity
after the first infection.
• If a transplant recipient has had COVID-19, he/she should wait until all
symptoms are resolved and the period of isolation has ended.
Can patients stop wearing a mask after vaccination ?
• NO…
• After vaccination, patients should continue to practice COVID-19 safety
measures including wearing masks around others, hand hygiene, and physical
distancing in public places.
• It is likely that the efficacy and immunogenicity of vaccine in transplant
recipients will be lower than shown in the vaccine clinical trials.
Taking immune suppressants can suppress immune
system. Do patient need to take special precautions with
regard to COVID-19?
Immunosuppressed patients should take the following precautions:
•Continue to wear a mask and practice social distancing in public, even after
receiving the vaccine.
•Wash your hands often with soap and warm water, scrubbing for at least 20
seconds each time. When soap and water are not available, use an alcohol-based
hand sanitizer that contains at least 60 percent alcohol.
•In addition to regular hand-washing, practice normal infection-prevention
techniques, such as covering your nose and mouth when coughing and avoiding
people who are sick.
Can we give other vaccines at the same time as COVID-19
vaccine ?
• There are no data on safety or efficacy of any vaccine getting affected due to
covid-19 vaccine.
• Although, It is recommended that the COVID-19 vaccine series should be
administered alone and with a minimum of 14 days before or after giving any
other vaccines.
Should we check for antibody response after vaccination
in solid organ transplant recipients ?
• Currently there is no recommendation of routinely checking antibody responses
to vaccine.
• There are a range of assays with different targets, not all detect neutralizing
antibodies, and most do not provide results with titers.
• Presence of antibodies may represent reaction to vaccine but not protection from
infection.
• There is not a well-established protective threshold to target.
Should patient hold immunosuppressants around the time
patients are vaccinated?
• Data is insufficient to support the reduction or cessation of any
immunosuppression to improve vaccine efficacy.

• Information regarding antibody response, cellular immune response and clinical

effectiveness of COVID vaccination in the transplant population is currently not
available.

• It is NOT recommended to adjust dose of immunosuppression prior to

vaccination.
How efficacy of vaccine gets affected by
Immunosuppressants?
•The risk of acquiring infection and the reduced ability of vaccines to prevent
infection are directly related to the degree of immunosuppression.

•Greater the degree of immunosuppression, the less likely the patient is to respond
to vaccines.
Which factors may contribute to immunosuppression in
body?
•Factors contributing to immunosuppression include the underlying disease (e.g.
renal or hepatic insufficiency)

•Presence of allograft rejection

•The immunosuppressants administered after transplantation

Which vaccines may provide protection in
immunocompromised patients?
•Protection of the immunocompromised patient may require the use of
vaccines and/or passive immunization (i.e. intravenous
immunoglobulin).

•Adjunctive measures, such as antiviral drug prophylaxis during

influenza A outbreaks.
Is vaccination recommended pre-transplant?
•Vaccines are generally more immunogenic if given pre-transplantation.

•Immunosuppressants given after transplant to prevent and treat

rejection may reduce the vaccine response.
Can patient be given a live vaccine post transplant ?
•Live vaccines, except BCG, can be given pre-transplant. BCG should
never be given post SOT.

•They should be given at least 1 month before transplant, but not to

those receiving immunosuppressive therapy.
Which live vaccines may be administered to transplant
patients?
•MMR vaccine can be given from 6 months of age and should be
given early if transplant before 13 months of age is anticipated.
•Varicella vaccine should be given to seronegative patients from 12
months of age.
•Live zoster vaccine may be given to transplant candidates aged ≥50
years if non-live vaccine is not available.
•BCG vaccine should not be given pre transplant.
Can patient be given a non - live vaccine post transplant ?
•Immunization should be completed at least 2 weeks prior to
transplant as a protective immune response is unlikely to be produced
if vaccines given after this time.
•Non-live vaccines can be given from 6 months post-transplant. If
immunization is not completed pre-transplant, then course should be
completed post-transplant.
Which non-live vaccines can be administered to transplant
patients and when?
•All age-appropriate immunization should be completed prior to therapy.
•Hepatitis A vaccine should be considered in all seronegative organ transplantation
candidates, particularly liver transplant candidates.
•Hepatitis B vaccine is recommended for patients who are anti-HBs negative.
•HPV vaccine is recommended for males and females in the appropriate
age groups, because of the increased risk of anogenital HPV-associated
neoplasia in SOT recipients.
•Inactivated influenza vaccine is recommended for all candidates from 6
months of age.
Which non-live vaccines can be administered to transplant
patients and when?
•MenB and MenACWY vaccines are indicated for those at increased
risk.
•PCV13 and PPV23 vaccines should be given if not previously
received.
•T dap should be given to those aged over 10, at least 10 years after a
previous dose.
•Zoster vaccine (ShingrixR) should be given to those aged ≥50 years
When should COVID 19 vaccine be given to transplant
patients?
•A primary course of COVID-19 vaccine should be given
pre-transplant followed by an additional dose at least 6
months later.
When can we start vaccination post transplant ?
•The degree of immunosuppression is greatest in the first 3 to 6
months post-transplant, but a significant degree of
immunosuppression persists.
•A minority of transplant recipients who experience chronic rejection,
persistent organ dysfunction, or chronic infections, remain
profoundly immunosuppressed.
•Vaccination should not be re-initiated until 3 to 6 months post-
transplant when baseline immunosuppressive levels are attained.
Transplant recipients are at risk of which infections?
•SOT recipients are at risk of severe illness or death due to influenza.

•They are also at increased risk of invasive pneumococcal disease,

H. influenza type b disease.

•Complications of HPV and varicella infection.

Any re-immunization is needed post-transplant ?
•Patients who receive non-live vaccines <2 weeks prior to transplant
should be re-immunized, starting 6 months post-transplant.

•Patients aged 6 months and older should receive annual inactivated

influenza vaccination.
Should children be vaccinated during the pandemic?
•All routine vaccinations be administered as scheduled, even during the COVID-
19 pandemic as it is an essential health activity.

•The benefits of immunizations far outweigh the associated risks.

Vaccines for SOT candidates
and recipients aged ≥10 years
•All patients require annual inactivated influenza
vaccine from 6 months of age (2 doses 4 weeks
apart in the first season of receipt)
Is your child at an increased risk for getting infected with
SARS-CoV-2 by the hospital/clinic visit for immunization
•If social distancing, mask, sanitization is strictly followed, and the recommended
COVID-19 related norms are observed in the immunization session, the risk is
minimal.
Is there a change in the existing immunization schedule
during the pandemic?
•There is no information about the effect of COVID-19 on responses following
immunization.
•It is recommended that in private practice settings, the existing ACVIP
Guidelines are to be followed for routine immunization.
•There is currently no need for a change in the immunization schedule.
Does vaccination increase a child’s risk of becoming
infected with SARS-CoV-2 or of developing COVID-19?
•Vaccination against one disease does not weaken the immune response to another
disease.
•Currently there is no evidence that vaccination would increase the risk of a child
becoming infected with COVID-19 or affect the course of the disease in a child
who has been inadvertently vaccinated during the asymptomatic phase or
incubation period.