Chapter 126. Infections in Transplant Recipients (Part 15) Virus-Associated Malignancies In addition to malignancy associated with gammaherpesvirus infection (EBV, KSHV) and simple warts (HPV), other tumors that are virus-associated or suspected of being virus-associated are more likely to develop in transplant recipients, particularly those who require long-term immunosuppression, than in the general population. The interval to tumor development is usually >1 year. Transplant recipients develop nonmelanoma skin or lip cancers that, in contrast to de novo skin cancers, have a high ratio of squamous cells to basal cells. HPV may play a major role in these lesions. Cervical and vulvar carcinomas, quite clearly associated with HPV, develop with increased frequency in female transplant recipients. Among renal transplant recipients, rates of melanoma are modestly increased and rates of cancers of the kidney and bladder are increased. Vaccination of Transplant Recipients In addition to receiving antibiotic prophylaxis, transplant recipients should be vaccinated against likely pathogens (Table 126-6). In the case of HSCT recipients, optimal responses cannot be achieved until after immune reconstitution, despite previous immunization of both donor and recipient. Recipients of allogeneic HSCTs must be reimmunized if they are to be protected against pathogens. The situation is less clear-cut in the case of autologous transplantation. T and B cells in the peripheral blood may reconstitute the immune response if they are transferred in adequate numbers. However, cancer patients (particularly those with Hodgkin's disease, in whom vaccination has been extensively studied) who are undergoing chemotherapy do not respond normally to immunization, and titers of antibodies to infectious agents fall more rapidly than in healthy individuals. Therefore, even immunosuppressed patients who have not had HSCTs may need booster vaccine injections. If memory cells are specifically eliminated as part of a stem cell "cleanup" procedure, it will be necessary to reimmunize the recipient with a new primary series. Optimal times for immunizations of different transplant populations are being evaluated. Yearly immunization of household and other contacts (including health care personnel) against influenza benefits the patient by preventing local spread. Table 126- 6 Vaccination for Hematopoietic Stem Cell Transplant (HSCT) or Solid Organ Transplant (SOT) Recipients Type of Transplantation Vaccine HSCT SOT a Streptococcus pneumoniae , Haemophil us influenzae, Neisseria meningitidis Immunize after transplantation (optimal timing not established) Use Prevnar Preimmunize donor (graft) b See CDC recommendations Immunize before transplantation and every 5 years for Pneumovax (others not established) S ee CDC recommendations Seasonal influenza Vaccinate in the fall Vaccinate close Vaccinate in the fall Vaccinate close contacts contacts Poliomyelitis Administer inactivated vaccine Administer inactivated vaccine Measles/mumps/rubella Immunize 24 months after transplantation if patient does not have graft- versus-host disease Immunize before transplantation with attenuated vaccine Tetanus, diphtheria Reimmunize after transplantation with primary series See CDC recommendations Immunize before transplantati on; give boosters at 10 years or as required; primary series not required Hepatitis B and A Reimmunize after transplantation See CDC Immunize before transplantation as appropriate recommendations Human papillomavirus Recommendations pending Recommendatio ns pending a Immunizations should be given before transplantation whenever possible. b Studies indicate that it is possible to "immunize the graft" before transplantation. . Seasonal influenza Vaccinate in the fall Vaccinate close Vaccinate in the fall Vaccinate close contacts contacts Poliomyelitis Administer inactivated vaccine Administer inactivated vaccine. are increased. Vaccination of Transplant Recipients In addition to receiving antibiotic prophylaxis, transplant recipients should be vaccinated against likely pathogens (Table 126- 6). In the. Chapter 126. Infections in Transplant Recipients (Part 15) Virus-Associated Malignancies In addition to malignancy associated with gammaherpesvirus infection (EBV, KSHV)