Introduction

Pediatric liver transplant recipients do not often achieve immunity to live and inactive vaccinations. Many have non-protective antibody titers as result of premature administration of vaccines or chronic illness. We developed the following Plan-Do-Study-Act (PDSA) cycle to guide consistent vaccine counseling. The following data reflects the 4-year outcome of the program.

Methods

· Measure antibody titers at each annual visit.

· Recommend vaccinations for patients without immunity based on the following criteria:

• All vaccines – no rituximab within 6 months
• Live vaccines:

1. ≥1-year post-transplant
2. Low titers for varicella, measles or mumps
3. Monotherapy immunosuppression with drug level ≤8
4. No rejection or serious infection within 6 months
5. No steroids within 3 months
6. No chemotherapy within one year

Results

· 51 patients participated in all 4 years of the program

· By year 4, 72% (n= 37/51) were immune to live vaccines, compared to 41% (n=29/71) at the start of year 1

· 10% (n= 5/51) received a recommendation for live vaccines in year 4, compared to 45% (n=32/71) in year 1

· 20% (n=1/5) received live vaccines and 11% (n=2/18) received inactive vaccines

· 6 patients had reactions to live vaccines, including mild local injection site rash and/or pain

Conclusions

We have successfully recommended vaccinations and documented immunity by implementing an active vaccine counseling program. There was a consistent annual increase in vaccine-induced immunity over the last 4 years with our vaccine management program. Additionally, the administration of live and inactive vaccines was safe and effective.