People with decompensated cirrhosis should be prioritised
for COVID-19 vaccination and immunosuppressive treatment after a liver transplant
should not be a barrier to vaccination, an international panel of liver experts
has concluded.
Their review of the available evidence is published in the journal
The Lancet Gastroenterology and Hepatology.
They point out that the evidence on vaccine efficacy in
people with chronic liver disease or post-transplant immunosuppression is very
limited.
Glossary
- ascites
An accumulation of fluid in the abdomen; may be caused by liver damage, especially cirrhosis.
- decompensated cirrhosis
The later stage of
cirrhosis, during which the liver cannot perform some vital functions and
complications occur. See also ‘cirrhosis’ and ‘compensated cirrhosis’.
- encephalopathy
-
A disease or infection affecting the brain.
People with liver disease were included in the trials of the
Pfizer and Moderna mRNA vaccines but excluded from the trials of the
Oxford/AstraZeneca vaccine. People receiving immunosuppressive treatment after
a liver transplant were excluded from trials of all three vaccines, as were
people with autoimmune liver disease.
The review does not discuss the vaccine developed by the
Chinese manufacturer Sinopharm, already in use in China, or the Russian Sputnik
vaccine.
The experts warn that vaccine responses will need to be
monitored in people with liver disease, as some liver conditions can weaken
vaccine responses.
People with cirrhosis are less likely to produce antibodies
after hepatitis B vaccination and have less durable responses to flu vaccine.
Similarly, people receiving immunosuppressive medication for liver transplantation
have weaker antibody responses to flu and hepatitis B vaccinations.
People with decompensated cirrhosis must be a high priority
group for vaccination, say the experts, due to their higher risk of death from
COVID-19.
Although vaccinations are usually recommended prior to liver
transplantation or after the transplant recipient has been stabilised on maintenance
immunosuppressive treatment, the experts say that COVID-19 vaccination should
not be delayed in liver transplant patients.
In the United Kingdom, the Joint Council on Vaccination and
Immunisation has decided that people over 65 will be prioritised for
vaccination, ahead of younger people with underlying
health conditions including chronic liver disease.
People with serious
underlying health conditions include the following groups in the United Kingdom:
- People with cancer receiving chemotherapy
- People having immunotherapy or other continuing
antibody treatments for cancer
- People on immunosuppression therapies sufficient
to significantly increase risk of infection
- People classed as clinically extremely
vulnerable on an individual basis by a general practitioner or hospital consultant, including people with decompensated cirrhosis or cirrhosis who have experienced ascites, hepatic encephalopathy, hepatocellular carcinoma, variceal bleed or synthetic liver dysfunction in the past 12 months.
In the United States, the US
Centers for Disease Control and Prevention (CDC) has recommended that in addition to people in
care homes and frontline essential workers, people over 75 should be vaccinated
first, followed by people aged 65-74 and people aged 16-64 who have high-risk
medical conditions. CDC has identified obesity, type 2 diabetes and
immunosuppression after organ transplantation as high-risk medical conditions.
CDC says that people with liver disease may be at increased risk. CDC also
stresses that multiple underlying health conditions place people at higher risk
of severe COVID-19 than a single underlying condition.
However, state governments in the United States are free to
vary these recommendations.
Vaccination is proceeding at a slower pace in European Union
countries and national recommendations vary.
The Australian
Technical Advisory Group on Immunisation has not specified people with
liver disease as a priority group for vaccination.