Will people with liver disease be prioritised for COVID-19 vaccination?

19 Jan 2021 Keith Alcorn
Originally published on www.infohep.org

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.

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.