Part IV: Vaccination in Special Populations

October 24, 2016

Renal and hepatic disease put your patients at high risk for vaccine-preventable disease. Find out what you know about how to protect them.

[[{"type":"media","view_mode":"media_crop","fid":"53147","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4766200529235","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6617","media_crop_rotate":"0","media_crop_scale_h":"250","media_crop_scale_w":"177","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]Another way to categorize vaccines for vulnerable populations is by the specific problems that predispose them to vaccine-preventable illnesses. Dialysis patients, persons with cirrhosis, and individuals without a spleen are such groups; so are pregnant women. There is an important reminder inherent in highlighting these clinical segments: while patients in each group are cared for by one or more specialists, they also need to rely on a primary care provider to ensure they receive basic preventive healthcare.

Dialysis/ESRD patients: we need to do better

Infection is the second most common cause of death in ESRD patients, with cardiovascular causes being the first.1 While immunization would seem like a straightforward preventive strategy, it is underutilized. The morbidity related to poor coverage of this group is compounded by a historically suboptimal response to routine vaccines among ESRD patients. Their immunosuppressed state and dialysis-related exposures make them vulnerable in an even more precarious way to infectious organisms.1




Answer: A. Only 65% of persons with ESRD received influenza vaccine in 2010.

Hepatitis B vaccination rates in this population were only 7.4% (2010); Pneumococcal 25.6% (2009-2010); and a single high dose immunization for influenza A in dialysis patients is required to provide immunity.1




Answer: All statements are true.1




Answer: B. The vaccination decreases the number of hospitalizations for heart failure.

The adjusted hazard ratio for heart failure hospitalization in influenza-vaccinated patients with CKD is 0.31.2 Protective effects were consistent across age groups studied (55-64, 65-74, ≥75), sex, and influenza seasonality.2




Answer: A. Pneumococcus B. H influenza B C. Meningococcus

Note that influenza vaccination is also recommended in asplenic individuals. Asplenic individuals are at risk for fatal sepsis. As a result, they also receive precautions when they experience fever similar to those for persons exposed to meningococcus.3


Cirrhosis: a pressing need for better vaccination practices.



Answer: All statements are true.

Primary care physicians need to take special care with cirrhosis patients to ensure they are immunized against pneumococcal infections as well as against hepatitis A and B if they are not immune. A superinfection with either or both of these viruses can be life threatening in this cohort.4



Answer: D. Is not correct

As early as 1879, it was known that the infants of mothers vaccinated against smallpox during pregnancy also obtained immunity against smallpox. But there are more potential infections during pregnancy for which vaccines can be protective for both mother and baby. Option D is the only incorrect answer.5,6 Mothers who received Tdap during the 28-38th week of pregnancy only experienced minor adverse events.6 Major events were not vaccine-related.


For Part I: Adult Vaccination: Patients with Diabetes Mellitus

For Part II: Older Adults

For Part III: Meningococcal and HPV Infections: Who’s at Risk?


1.  Soni R, Horowitz B, Unruh M. Immunization in end-stage renal disease: opportunity to improve outcomes. Semin Dial. 2013;26:416-426.;jsessionid=6BEAD64A884CB7B5B807E2409778A01B.f03t03

2. Fang YA, Chen CI, Liu JC, Sung LC. Influenza vaccination reduces hospitalization for heart failure in elderly patients with chronic kidney disease. A population-based cohort study. Acta Cardiol Sin. 2016; 32:290-298.

3. Rubin LG, Schaffner W. Clinical practice: Care of the asplenic patient. N Engl J Med. 2014; 371:349-356.

4. Waghray A, Waghray N, Khallafi H, Narayanan Menon KV. Vaccinating adult patients with cirrhosis: trends over a decade in the United States. Gastroenterol Res Prac. 2016.

5. De Martino, M. Dismantling the taboo against vaccines in pregnancy. Int. J. Mol Sci. 2016; 17:894.

6. Petousis-Harris H, Walls T, Watson D, et al. Safety of Tdap vaccine in pregnant women: an observational study. BMJ Open. 2016;18:e010911. Doi: 10.1136.