Welcome everyone to the 2020 academic debates. Today's topic is live vaccines and pediatric liver transplant recipients to give or not to give. This session is taking place live Saturday, November 14th from 615 to 7pm Eastern Standard Time, but the recording can be played on demand before the liver meeting digital experience closes February 15th, 2021. We are the program chairs, Dr. Uchenna Agbem, Oren Fix, and Christina Lindenmeyer that plan this event for you to enjoy. As this activity will be available for AMA PRA Category 1 credits and ABIM MOC points, we will be providing disclosures for all faculty. These are our disclosures. We would like to present our Master of Ceremonies, the esteemed Nancy Rowe of Rush University Medical Center in Chicago, Illinois. We are also honored to have a couple of experts in the field, Dr. Emily Rothbaum-Perrito of the University of California, San Francisco, and Dr. John Bucavales of the Icahn School of Medicine at Mount Sinai, New York. These panelists will challenge and critique our debate teams following their initial arguments and rebuttals. These are our disclosures for our emcee and panelists. You, the audience, will be asked to vote on the best argument presented. As you listen to each team, critique them on the following, construction of the argument, quality of their argument slides, mastery of the topic, their presentation styles, and their skill in responding to questions. For all of you in the audience joining us in the live session, Saturday, November 14th, from 6.15 to 7 p.m. Eastern Standard Time, you get to vote on which team you think had the best argument. Polling will open following the full set of debate presentations, including the panelists and audience questions and answers. Once that has taken place, we will prompt you to go to the tab here in TLMDX called Polling to submit your vote. The winner will be announced at the end of the session. Also, the Q&A is open now, and at any time, you may submit a question, as we will cover as many as we can during the audience Q&A. So now, without further ado, let's move into the debate and the debate teams. Thank you so much. Today's debate will be centered on the topic, live vaccines in pediatric liver transplant recipients, to give or not to give. We'd like to acknowledge Dr. Amy Taylor of Cincinnati Children's Hospital and who serves on the AASLD Training and Workforce Committee for her assistance in developing the argument and submission criteria for this, AASLD's first pediatric-focused debate. Now, here are the arguments that will be debated. The pro is liver recipients are often incompletely immunized and would benefit from live vaccination after transplant. This is compared to the con, which is the risk of injury from attenuated viruses in immune-compromised liver recipients is too great to allow immunization. The first argument, liver recipients are often incompletely immunized and would benefit from the live vaccination after transplant, will be given by Children's Hospital of Philadelphia, Ta-Issa Kohut and Tamara Diamond, with the support from their faculty mentor, Elizabeth Rand. Here are their disclosures. And now I'm going to let Chopp take it away. Thank you, Dr. Rowe, the organizing committee and the panel for inviting us to be one of the first two pediatric teams to compete in the AASLD debate. Like Dr. Rowe said, we have no financial disclosures, but we do quote our rivals in multiple places during this presentation, so I cannot confirm nor deny any quid pro quo or collusion with the other team. Well, let's start with reviewing immunizations. With any medical intervention, we have to weigh the risk and benefit it may have in our patient population. Historically, live vaccines were not recommended to pediatric liver transplant recipients due to perceived safety risks related to inducing a live attenuated vaccine illness or precipitating acute rejection. In addition, because our patients are on immunosuppressive drugs, there is a decrease in efficacy of these vaccines in our transplant population. However, outbreaks of vaccine-preventable diseases are on the rise in North America and Western Europe over the last two decades, as can be seen in the data from the CDC showing increase in measles outbreaks over the last two decades, specifically in the Magic Kingdom. This is due to recent lapses in herd immunity due to the anti-vaccine movement, as well as international travel. And these vaccine-preventable diseases can cause significant morbidity and mortality in our population, as we'll describe later. Even prior to transplant, our patient population has decreased in efficacy of vaccines compared to healthy controls. In data showed by Wu et al. published in Vaccine in 2009, biliary atresia patients had lower titers compared to healthy controls that were age-matched in varicella, rubella, and measles. In addition, Feldman et al. showed that a review of 7,000 pediatric solid organ transplant recipients had an 87 times higher risk of being admitted to the hospital compared to healthy children in the five-year term post-transplantation. This is exemplified by a case we had in our institution of a child that was vaccinated at one year of age, was transplanted at 17 months of age, and then disseminated varicella 22 months of age, five months after transplantation, and required a prolonged admission. Now we have this preventable risk to our patient population, but as a community, we're doing a very poor job in preventing these infections. In a survey of 39 pediatric liver centers, including 281 pediatric liver transplant recipients, only 29% were up to date according to the CDC schedule for their age, and 90% were up to date according to the IDSA schedule for their age. That's a similar immunization rate to a pediatric practice that's run by Jenny McCarthy. So we have an unimmunized population that has decreased immune response even prior to transplantation, and in addition, we provide them immunosuppression. This makes them highly susceptible to infections and complications related to it. Now it seems like the main limitation of us moving forward and immunizing our children is concerns about safety and efficacy. As shown by Kemi and Al, that 69% of centers that are part of SPLIT would start a live immunization program in the next one to two years if they would have more data regarding safety from the AST. Now we'll show that they are actually pretty safe. Regarding safety, so Suresh and Al reviewed six prospective studies in addition to case reports, case series over the past three decades, and included 200 pediatric liver and kidney transplant. During this three-decade period, there was only one case of acute cellular rejection that was correlated only by time to the measles vaccine, and that was in 1993. In 1993, while our team actually published that paper from University of Chicago and was mingling with future Hall of Fame Dallas Cowboys, the hottest thing happening in Denver was a visit by His Holiness at Mile High Stadium. At that season, the Broncos did not do very well. Suresh and Al summarized the two-day consortium of interdisciplinary teams from infectious disease immunology and transplant, and published guidelines for immunization for liver and kidney transplant recipients. These are extensive, and we can see them to the right in the table on the screen. At the Children's Hospital of Philadelphia, we keep things a bit more simple. Patients have to be clinically well and over six months off of steroids and on monotherapy immunosuppression at the time of vaccination. The other question is related to efficacy, and seroconversion rates in our population are lower compared to healthy children. However, Verilet et al. actually showed in a series of 49 patients in Switzerland after transplantation that 97.5% of the children were able to seroconvert after one or two doses of varicella vaccine. In addition, Pofse-Barr et al. published in AJT that the CD4T lymphocyte response in patients receiving varicella immunization after transplantation actually increased, suggesting that there's also an adequate cellular response to varicella vaccination. In summary, we suggest to follow the data and not pseudoscience. These infections can cause significant morbidity and mortality in our population. We've established that they are safe and efficacious in our patient population. And after providing you with this data, the team from Colorado will have to strain really hard in order to convince you otherwise. Thank you, and go Team CHOP. Excellent concluding slide. The second argument, the risk of injury from attenuated viruses in immune-compromised liver recipients is too great to allow immunization, will be given by Children's Hospital of Colorado, Dr. Sarah Kemi and Julia Boster, with support from their faculty mentor, Amy Feldman. Here are their disclosures. Take it away, Colorado. Thank you. First, I would like to thank the ASLD and panelists for inviting us to debate this important and very timely topic. When we start medical school on the long journey to becoming a physician, we take an oath to first do no harm. Hippocrates may not have been speaking directly on the subject of live vaccines following liver transplantation or directly to our colleagues from the Children's Hospital of Philadelphia, but this doctrine can and should be applied to the topic. As such, we must critically consider the risk of inducing a vaccine strain infection in an immunocompromised host by giving live vaccines after liver transplant. Live vaccines are attenuated, not killed. They are designed to replicate in small numbers, but not to cease all replication. In an immunocompromised host, replication of a vaccine strain attenuated virus may be enhanced and can lead to disseminated vaccine strain disease and resulting severe morbidity and or mortality. Let's describe what could potentially happen if an immunocompromised transplant recipient became ill with vaccine strain varicella or measles. Let's start with varicella zoster virus. Varicella infection may seem harmless enough, and in an immunocompetent healthy child, it usually only results in an itchy rash. But the children we care for are not immunocompetent as they are on lifelong immunosuppression. Children who are immunocompromised don't just get itchy skin for a few days. They can suffer from disseminated varicella infection leading to pneumonia, hepatitis, encephalitis, disseminated intravascular coagulopathy, and even death. Though varicella can be treated with acyclovir and varicella immune globulin if recognized in a timely fashion, unfortunately, immunocompromised children often don't develop the typical vesicular rash, making the diagnosis of varicella more difficult and thus not allowing for prompt initiation of treatment. These are not just hypotheticals to scare you. Solid organ transplant recipients have previously developed disseminated varicella infection with vaccine-strained virus after vaccination. Here is one example of vaccine-strained infection in a liver transplant recipient that led to hospitalization and need for IV antiviral treatment. But at least we have treatment for varicella. If Dr. Diamond, Dr. Cohut, or Dr. Rand gives vaccine-strained varicella infection to a transplant patient, Dr. Diamond can at least attempt to clean up the mess. However, measles is a potentially fatal disease with no therapies available outside of supportive care. One in three children with measles will develop a complication. Sometimes the complications are mild, such as development of a rash, conjunctivitis, cough, choriza, diarrhea, or otitis. But often measles can result in severe complications or even death. One in four children with measles will require hospitalization for severe symptoms. As many as one in 20 children with measles develops pneumonia, and about one in every 1,000 children with measles develop measles encephalitis, which can have devastating long-term effects. And not all children are lucky enough to survive measles. Measles has a mortality rate of two per 1,000 healthy patients in the U.S. Even if a child recovers from measles, they can develop subacute sclerosing panencephalitis, a fatal degenerative disease of the central nervous system characterized by behavioral and intellectual deterioration and seizures seven to 10 years after infection. Remember that measles has a mortality rate of two per 1,000 healthy patients in the U.S. However, 40 to 70% of immunocompromised children who contract measles will die. Let us repeat that scary fact again. 40 to 70% of immunocompromised children who contract measles will die. Again, we aren't trying to scare you with hypotheticals. Here are examples of vaccine-strained measles in immunocompromised individuals from the literature. Remember that we do not have therapy for measles outside of supportive care. Thus, a healthy transplant recipient could die from infection caused by a vaccine. So, the question becomes, are the potential risks of acquiring vaccine-strained varicella or measles after receiving a live attenuated vaccine worth it? Although measles cases have been increasing over the last 10 years, there were still only 1,500 cases in the U.S. in 2019 and only 12 so far in 2020. That is not very many. And thankfully, our patients are somewhat protected due to herd immunity, where vaccination of the healthy population protects those who cannot receive the vaccine and acquire their own immunity. The overall rate of measles vaccination of kindergartners across the U.S. remains above the 90 to 95% threshold needed for herd immunity. Only two states have vaccination rates below 90, but remain at 87.4 and 89.5%. Why risk inducing vaccine-strained disease if the risk of contracting wild-type disease is so small? Bad things don't just happen in Philadelphia. Bad things can happen anywhere if live vaccines are given to immunocompromised hosts. In summary, we ensure we do no harm to our patients as we pledged when taking the Hippocratic Oath at the beginning of our medical careers. Instead of giving live attenuated vaccines to immunocompromised transplant recipients, we propose focusing on providing live vaccines to every eligible child pre-transplant and working with our general pediatric partners to ensure healthy children receive vaccines so herd immunity can be maintained. Thank you very much. Well, thank you for that. I'm going to invite our teams back now for their rebuttal. So we are going to start with Chok. Why don't you respond to your criticisms here? Our fellow Colorado colleagues have made a valiant attempt to convince us against live vaccines in pediatric liver transplant recipients after transplant. But clearly, the thin Colorado air plus the marijuana fumes have clouded their judgment. We respectively disagree not only with Colorado's decision to name their NHL team after the most common natural disaster, but we also disagree with Colorado children's debate points. Interestingly, hepatologists are accustomed to and very comfortable with managing lifelong immunosuppression medications with many potential adverse effects, including but not limited to malignancy and chronic kidney disease. Yet the hepatology community largely fears live vaccines after transplant due to the dated and honestly rather theoretical risks that our opponents have presented. Dr. Diamond has eloquently highlighted three decades worth of data supporting the safety and efficacy of live vaccines after transplant. Contrary to what our opponents argue, the risk of injury from attenuated viruses in immunocompromised liver transplant recipients does not outweigh the benefits of immunization. Vaccine type virus reactivation has been rarely reported, except maybe for the case reports that our opponents presented from 30 years ago when we're using much more immunosuppression. And, you know, perhaps the case of varicella in a 60-year-old may not be relevant in this situation. And they have not been associated with severe outcome or morbidity. In contrast, we have shown you that primary measles and varicella infection after transplant can be associated with significant morbidity and mortality and may even precipitate allograft rejection. And so while a certain individual in the White House may think bad things happen in Philadelphia, one very good thing happening in Philly is our pediatric liver transplant recipients are receiving their live vaccines and safely able to do so, a practice that has been very well tolerated at CHOP for many years. And we urge all pediatric liver transplant centers to implement live vaccines after transplant as part of their standard of care. In conclusion, I think it's pretty obvious that the Philadelphia Eagles have outdone the Denver Broncos yet again. And it's now time for us to celebrate with a classic Philadelphia cheesesteak, which we think, like our presentation, is much more genuine than the world-famous Colorado oysters made from Colorado's finest bull testicles. Thank you for your time and consideration. And remember to vote for Team CHOP. All right. That was a pretty personal rebuttal there. We're going to let Colorado respond to Team CHOP. Hopefully, no fatty liver disease from the Philly cheesesteaks, though. As much as our colleagues from Philadelphia are reaching for evidence that live vaccines are safe in immunocompromised children, the strong data just doesn't exist yet. In order to power a study to detect adverse events that occur in one in every 1,000 patients, you need more than 50 patients in a study. This research is ongoing in a national effort, but this data just doesn't exist yet. So now we completely understand why the Fresh Prince left Philadelphia for greener pastures in Bel-Air. The evidence that our colleagues are presenting is limited at best. Note that the studies they present are expert opinions, single-center case studies, and prospective cohort studies. There are no randomized controlled trials that have been performed to date. Before live vaccines can be recommended for transplant recipients, large, multi-center studies with appropriate power to detect serious events are needed. Tamir, sorry, Dr. Diamond from Philadelphia is going to talk a little bit more about this. Dr. Diamond from Philadelphia did comment on the recent survey study, and he's correct that the North American hepatologist, when surveyed, only 12 of 41 centers are offering live vaccines to post-liver transplant patients, and the majority of centers are not offering live vaccines because evidence is still lacking on safety and efficacy. I think it's worth noting that this survey study was put out after the Suresh consensus statement, so even though we have a consensus statement, many centers, the majority of centers, really, are still very hesitant about giving vaccines to this population. So, in summary, vaccine-strained measles can be fatal for an immunocompromised transplant recipient, and we have no treatment. To date, studies assessing MMR and varicella vaccine safety post-liver transplant have been underpowered to assess serious adverse events, and the majority of pediatric transplant centers at this time do not endorse live vaccines. So, it's important to ask yourself, is it worth the risk of iatrogenic morbidity and mortality to provide a vaccine to transplant recipients to protect them against measles, a disease that they're unlikely to contract in the first place? And finally, can we rely on underpowered and low-tiered evidence that have been presented today to justify vaccinating children with live vaccines after transplant? Thank you so much. All right. Well, now that our teams have interrogated each other quite creatively, I'm going to turn to our panelists to ask them to pose some tough questions and to provide their critiques of our two presentations. I'd like to know from the two teams how COVID changes this. COVID is obviously very real for all our families and all of us right now, and measles and mumps and rubella are real but not, you don't think you're going to like necessarily get it from going to the grocery store. So, how does COVID impact this discussion, and should it change what we're recommending or how we talk about this to families? From the Team CHOP standpoint, I think COVID has made all of our patients and their families be fearful to continue with appropriate primary care and are not going to their pediatricians for appropriate immunizations. And that is just leading to waning herd immunity. And that in itself is putting our patients at increased risk for these disease preventable, vaccine preventable diseases. So COVID would actually make me more inclined to provide live vaccines to our transplant patients. All right, so from our standpoint, we have seen some decreased immunization during the COVID pandemic in the United States. Although the, really the rates of decreased immunization in that age group for that first MMR and varicella vaccine, which they usually get at one year of age, is not significantly impacted. It's more the older children who are getting less of their vaccinations. And so I think we still have the herd immunity that we need across the United States. I would also argue that now more than ever, we want to protect our transplant patients. If we give them a vaccination that induces vaccine strain illness and then they are hospitalized, they're hospitalized in the era of COVID. And what risk are we putting them at in that situation? So I'm trying to figure out, first thing is, it's really good that both sides agreed to do no harm. That was the first thing. I really congratulate you for not trying to harm patients on both sides. So that was excellent. And I'm a little worried about herd mentality, like thinking about the whole country. So when you take an average rate for the country, I'm trying to figure out what happened in Brooklyn last fall. How come all those people got measles? And why did everybody up here, and I know it's a blue state in the mid part of the country, doesn't really care about the Northeast and all that, but what happened? I mean, if everybody's protected, then what happened in Brooklyn? Yeah, so the outbreak that you're just, that you're mentioning at the moment, that was actually in an Orthodox Jewish population in New York that are with basically pockets of under-immunized children. And that was one of those pockets, was based on religion, they are not vaccinated. And so while there was that outbreak that led to about 1500 cases in 2019, the majority of those cases were in New York. Once the outbreak had ceased, we went back to our prior status of being measles-free at that point. So that was a pocket, but we have herd immunity. I don't know if the Philadelphia group has any comment about that. Well, I mean, that's exactly our point. It actually, the infection in that community came from travelers internationally that were in the Ukraine where measles is still prevalent in Oman, which is a pilgrimage area. And that's exactly what we were saying is that if you have these international travelers that are coming in a community that is not entirely immunized, that actually exposes our patients a lot more to these live strains, these live vaccines. A wild type of infection is much more dangerous according to the data that we showed compared to a live attenuated vaccine. So as long as the COVID pandemic continues, and people aren't traveling as much, it doesn't really matter if kids get immunized and everybody's okay, right? So that's the strategy. I mean, is that, am I misunderstanding the argument here? So, I mean, there's still the possibility of having infection in the community. International travel is not totally gone and you can still have infections from outside the community, maybe less so with measles, but definitely with varicella, which is still prevalent in the United States. I would expect the last comment to the Philadelphia community. I'd expect with Dr. Rand as your mentor, that you've come up with a snarkier response than that. They do get the best points for celebrity snapshots, thanks to also Dr. Rand, their mentor. Can I make one more point to Dr. Bukovales' last point, which is that a lot of these infections, when we're quoting about measles outbreaks, are occurring in pockets of the United States. And so I think it's important to consider that when we're talking about extrapolating these events to an entire transplant community, where when the risk is not the same across the whole country. Actually, that's a really good point. I think that that's one of the problems that we see, is that there are pockets all across the United States. And that's a very good point. So I wanna know from both teams, if this is really the right place to be focusing our attention and resources. There's gonna be cases on either side, the kid gets the infection from the vaccine, or the kid gets the infection without getting the vaccine. Is this the most effective, safest place where we can be focusing our efforts if we have some limited time to talk to families of liver transplant recipients about vaccines? I mean, it's a pretty easy intervention for us to do. All we have to do is keep good notes on our children's being vaccinated, talk to our families, which is, I think, entirely free, or maybe with some cost for spending more time in the office. But there's actually a study from Canada from the early 90s that showed that even with live vaccines, the cost, and that's Canadian dollars, and that's in the 90s, was much lower than the complications of hospitalization for patients with liver transplant that had a wild type infection. So I think that it is a very easy and feasible intervention that we can do to improve the wellbeing of our patients. And just to add, Samir, I think change takes time. Both teams presented a survey that said only about 30% of transplant centers are providing live vaccines now, but that same survey also said that over the next one to two years, the other 69% felt that they would likewise implement live vaccines. So it takes time to be educated. It takes time for guidelines to be put in practice. So I do think our transplant community as a whole, the thinking about this is shifting and changing, and we're gonna see this happening more often. And so I would like to argue, just in response to the question at the beginning, I think our colleagues from CHOP presented a lot of really important data about how scary wild-type varicella or measles can be, especially in one of our transplant recipients. And I think that dedicating the resources to vaccine-preventable infections in these transplant patients is incredibly important. They brought up a study from Dr. Feldman that one in six transplant recipients will be hospitalized with a vaccine-preventable infection in the first five years after transplant. I wanna say it ends up increasing the median cost of that hospitalization by about 120,000. So it's important. Our argument though is we just don't have the data to give those vaccines after transplant. And we really, really need to be focusing on giving these vaccines pre-transplant as well as to healthy children, really focusing our vaccine campaigns because we're pediatricians first. And so we should never forget that. There are studies that show that only about 19% of children going into transplant are actually have received their live vaccines. The data, it's about a quarter of the six to 11-month-old, six to 11-month-old children who get their accelerated vaccines, and only 15% got varicella. So we really need to be doing a better job. And I think Chopp did a great job of pointing out why it's so important that we need to immunize. It just needs to happen before transplant because we don't have the data for after. And we definitely will not disagree that we need to do a better job before transplant, but we know that that is not enough and that does not prevent our patients from getting primary measles and varicella. So we need to take advantage both before, but we can't forget after transplant as well because immunizing before doesn't get them out of the woods for this. I wanna thank both Chopp and Colorado, their mentors, the panelists, all of you that have viewed this. I suspected, and it's been confirmed that pediatricians are a more fun population than adult medicine. If you had been watching an adult vaccine debate, would have been all data slides and no cartoons. We don't even know anything about social pop culture. So you've beaten us there. This is not over though. So I want to remind the audience that we're turning to you now to poke holes into the arguments before we vote. So I want you to submit any questions you have in the Q&A tab. These will be addressed. Our teams will again be forced to comment on these difficult questions. And then we will come to a conclusion and determine a winner. As we gather audience questions to present to our team, we do wanna take a couple of minutes to thank everyone who made this debate possible. First, thanks again to our teams, Children's Hospital of Philadelphia and Children's Hospital of Colorado for putting forward such a great effort and enthusiastically jumping into the debates this year in this completely new format. The pandemic has definitely done a lot of reformatting for us and I wanna congratulate you for tolerating this alternative platform. You've done an excellent job. Thank you to our panelists. These were some great hard-hitting questions. Thanks again to Dr. Amy Taylor at Cincinnati Children's Hospital for her support in developing a pediatric-focused debate, our first, but certainly not our last. And finally, I wanna thank the program chairs and the ASLD staff who worked to develop this event and have it all come together. I'm also happy to announce that as editor of ASLD's journal, Clinical Liver Disease, I am pleased to continue the tradition I started a few years ago of inviting all of our debate teams to submit their debate arguments in a special article. They are released as a pair. And so as a reader, you would be invited to read both sides. And we do try to advertise the winner, although not until the very end. And in case you've missed it, a debate took place last night on the topic of liver transplantation in the times of COVID-19. It was alluded to that this is an important conversation even in our today's topic. So to transplant or not to transplant, that debate and today's have been recorded and can be played on demand before the liver meeting digital experience closes February 15th, 2021. Thank you. Teams, it's been a great debate and very lively. I want to reemphasize the creativity and the effort you've placed in here, and it really made it a very enjoyable evening. I want to offer a couple of reminders to the audience before we begin answering the questions. On the right side of your screen, there are two tabs, a Q&A and a chat. You're going to submit your questions in the Q&A tab. Please indicate which team or speaker you would like to direct that question toward. We will do our best to answer as many questions as we can. Use the chat tab to engage with other attendees and share resources. If we don't get a chance to answer every question today, the liver meeting digital experience offers a unique opportunity to connect with presenters through the platform. Navigate to your network and engagement center to search for a presenter by name. You may add them to your list of connections or request to schedule a meeting. Following the audience Q&A, we will ask all of the audience to go to the polls tab under the Q&A tab, where they will vote on which team they feel gave the best, strongest argument. So don't leave early. We want you to vote. You do not get a sticker like you did if you voted on the presidential election, but we will feel very excited about the fact you contributed to selecting a winner between our two teams. So now let's dive into the questions from our audience. I'm going to direct the first to Dr. Diamond, and that's if a parent would refuse to vaccinate a child, is this a contraindication to listing for transplant? That's a great question, Dr. Rowe, and it's a complicated ethical question about autonomy for patients and patients' parents. I think the kind of perception that we have here as a practice and I have as well as a future hepatologist is that liver transplantation is 21st century medical intervention. So part of the deal is being willing to comply with 21st century interventions that are available. So, you know, vaccinations prior to transplantation and after transplantation should be part of the discussion and should be agreed upon between us and the parents. You know, it's an easy enough intervention, as we said in the debate itself, to prevent morbidity and mortality and survival in our patient population. So it would be a definite contraindication from my end to proceed with listing. Thank you. Our next question we're going to target to Dr. Kemi, and can you think of a situation when you would consider a live vaccine post-transplant? Thank you. That is a great question. I would say the CHOP team did present some good data. I mean, it's underpowered data, but it's what we have. And so they did present some data that in a select transplant recipient who is on low-dose immunosuppression, clinically well, not currently having an acute rejection, you could consider vaccinating in that case. And so I think it's important to really view every child based on their clinical scenario. The question really is, though, what dose of immunosuppression is low enough that we know that it can be safe for those children? And it's important that we look prospectively at that going forward as well. All right. That's a natural segue to our next question, which I'll direct to Dr. Kohut. And that's if you do have a vaccinated individual that has a measles strain from that vaccine, how do you plan to manage that? Thank you for that question. If I was faced with the unfortunate circumstance, but I do have to mention rarely reported circumstance of managing a patient with vaccine strain illness, I'd be forced to deal with it in the same way that I would deal with wild type measles, which is supportive therapy. Unfortunately for measles, we don't have antivirals. Our only option is to treat them supportively. However, I do want to mention that overall with transplant hepatology, this is a delicate balance. And overall, I do think that the risk of injury associated with attenuated virus just does not outweigh the benefits of immunization. And our colleagues did a great job of digging into the literature and showing us some case reports of vaccine strain illness. But I personally don't feel that that evidence was strong enough. You know, those case reports were from 30 years ago. They were in adults on triple immunosuppression therapy. And, you know, the case reports from the 1970s to 90s for the measles strain virus reactivation were in immunocompromised patients that were not necessarily solid organ transplant recipients. So I just don't think the evidence there is strong enough either. Thank you. The next question is targeted to Dr. Boster. And it's been recognized that there aren't a lot of great large power, you know, double blind studies to help you with these, you know, difficult decisions. So how would you suggest finding evidence in a way that balances advancing care while still maintaining safety? It's a great point. And it's no secret that in pediatrics we are well accustomed for better or for worse to operating under inadequate data or sort of soft data at times. And that's not different in pediatric transplant. But that doesn't mean we don't keep trying to do better, especially when we are talking about such a critical topic as we are tonight. So just to reiterate, we completely agree with our CHOP colleagues that we need better data and we need to study prospectively the safety and efficacy of live vaccines after transplant in children. Where we differ is in the assertion that we already have that data to suggest that it is safe and efficacious. And I think it's an important point when we're talking about how to consent and how to enroll in studies giving live vaccines after a liver transplant. All right. So we have a couple of questions that are focused around the COVID pandemic. And it's, you know, untoward complications with even the concept of vaccinations at all. So I'm going to go back to Dr. Diamond. How are you going to talk to a patient who's now very concerned about vaccine after seeing sometimes some of the misinformation or the many stories that are coming about the several different COVID vaccinations that are available? So just like any conversation, you know, that we had even before COVID, there was a lot of misinformation regarding immunizations in the pediatric population. And I think the best way is to really talk about the data and the safety of vaccines. That is usually the way to really kind of have the discussion with families. And to explain that, you know, the risks that are related to it are usually at a very small number of patients, if any. So having a, you know, a strong relationship that interpersonally with the family and providing the data is something that we have been doing for, you know, decades as pediatricians. And even with the misinformation that's related to vaccines, related to COVID, is nothing new to us and is part of our training. So I would address it just as I addressed it as an intern in my continuity clinic. Thank you. Again, I want to thank the audience for the great questions, our panelists, the mentors. This has been an amazing end to a very great day at ASLD virtual. Now it is the time to vote. You have a little less than two minutes. So please go to that Q&A tab and the sub-tab polls. Vote for the team that you feel has given the best argument. And we feel bad. It's going to be a really hard choice. You have to pick one. You can't vote twice. Remember our criteria. Number one, construction of an argument. Number two, quality of their argument slides. And that doesn't always mean good pictures. Number three, mastery of the topic. Number four, their presentation style. And number five, their skill in responding to the questions. All right. It has been going. So you can see the tabs here so that if you aren't getting the votes that you want, I want you to call your friends. No, not your mom. But we want to make sure that we encourage everyone to vote. We've only got a little bit left to this time. I want to encourage everyone to have their vaccinations. Even if you're not a post-transplant child, you don't have to get the live vaccine or get all of the other normal ones. That includes your flu shot. I know that I have at least four debate team members I can reach out to when I'm trying to negotiate the several options for COVID vaccinations and trying to explain to my adult patients why they do or do not want one or why they want all nine were just released onto the market. Maybe that's a good idea. Maybe that's not a good idea. And I think that this has been a very timely, you know, given the COVID, you know, kudos to the person who found the question because I think it is, there's never been so much conversation around vaccinations, I think, ever. So great topic. I am trying to see the polling results. I feel like I was so trying to be above yesterday's event where the moderator couldn't see any of the results, but apparently I got logged out because I wasn't busy maintaining both of my monitors. So Katie's going to have to give me a cheat sheet about who won. Since I can't see it anymore. And let me see if there's anything else I'm supposed to say. While we wait for the winner to be announced. Oh, here it is. Oh, this is close. The debate is a great success. CHOP got 57%. So thank you for joining this always fun and popular academic debates. Look forward to the CLD where you can revisit them and maybe see if the authors change their arguments at all after giving them live. If you missed some of the session, it will be available on the Libber meeting on demand until February 16, 2021. At the conclusion, attendees will receive information on how to obtain a certificate of attendance, CME certificate, and or complaint, complain, claim, ABIM mock points. No complaints. We do hope you enjoyed this session and the rest of the conference. Thank you so much and good night. Good night.

academic debate

live vaccines

pediatric liver transplant recipients

Children's Hospital of Philadelphia

Children's Hospital of Colorado

vaccine-preventable diseases

attenuated viruses

post-transplant vaccination