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Original Investigation
January 14, 2019

Incidence of Hospitalization for Vaccine-Preventable Infections in Children Following Solid Organ Transplant and Associated Morbidity, Mortality, and Costs

Author Affiliations
  • 1Digestive Health Institute, Section of Gastroenterology, Hepatology and Nutrition, Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Children’s Hospital Colorado, Anschutz Medical Campus, Aurora
  • 2Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Children’s Hospital Colorado, Anschutz Medical Campus, Aurora
  • 3Section of Pediatric Infectious Diseases, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora
  • 4Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
  • 5Department of Pediatrics, Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Children’s Hospital Colorado, Anschutz Medical Campus, Aurora
JAMA Pediatr. Published online January 14, 2019. doi:10.1001/jamapediatrics.2018.4954
Key Points

Question  Are vaccine-preventable infections a common cause for hospitalization after pediatric solid organ transplant?

Findings  In this multicenter cohort study of 6980 pediatric solid organ transplant recipients at a Pediatric Health Information System center, 16% of individuals had at least 1 hospitalization for a vaccine-preventable infection in the first 5 years after transplant. Children who received transplants when they were younger than 2 years and transplant recipients of lung, intestine, heart, and multivisceral organs were at increased risk for hospitalization with a vaccine-preventable infection.

Meaning  Vaccine-preventable infections are common after pediatric transplant; therefore, maximal efforts must be made to ensure complete immunization of transplant candidates and recipients.

Abstract

Importance  Pediatric transplant recipients are at risk for vaccine-preventable infections owing to immunosuppression, suboptimal response to vaccines before and after transplant, and potential underimmunization if transplant occurred early in life. However, the incidence and burden of illness from vaccine-preventable infections in this population is unknown.

Objectives  To evaluate in pediatric solid organ transplant recipients the number of hospitalizations for vaccine-preventable infections in the first 5 years after transplant and to determine the associated morbidity, mortality, and costs.

Design, Setting, and Participants  A retrospective cohort study from January 1, 2004, to December 31, 2011, with 5 years of follow-up per participant (unless they died during the study period). The participants of this multicenter study through the Pediatric Health Information System were solid organ transplant recipients who were younger than 18 years at the time of transplant. Analysis began in July 2017.

Exposures  Transplant.

Main Outcomes and Measures  Hospitalizations for a vaccine-preventable infection during the first 5 years after transplant were ascertained using International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, clinical modification diagnosis codes. Data were collected on clinical care, outcomes, and costs during these hospitalizations.

Results  Of 6980 transplant recipients identified, there were 3819 boys (54.7%), and the mean (SD) age at transplant was 8 (6.2) years. Overall, 1092 patients (15.6%) had a total of 1490 cases of vaccine-preventable infections. There were 195 of 1490 cases (13.1%) that occurred during transplant hospitalization. The case fatality rate was 1.7% for all infections. Excluding infections that occurred during transplant hospitalization (when all patients go to the intensive care unit), 213 of 1257 patients (17.0%) were hospitalized with a vaccine-preventable infection requiring intensive care. In multivariable analysis, age younger than 2 years at time of transplant and receipt of a lung, heart, intestine, or multivisceral organ were positively associated with increased risk of a hospitalization from a vaccine-preventable infection.Transplant hospitalizations complicated by vaccine-preventable infections were $120 498 more expensive (median cost) than transplant hospitalizations not complicated by vaccine-preventable infections.

Conclusions and Relevance  Hospitalization for vaccine-preventable infections occurred in more than 15% of solid organ transplant recipients in the first 5 years after transplant at a rate of up to 87 times higher than in the general population. There was significant morbidity, mortality, and costs from these infections, demonstrating the importance of immunizing all transplant candidates and recipients. Further research on improving immunization delivery, preventing nosocomial infections, and monitoring response to vaccines in the transplant population is needed.

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