Immunization after hematopoietic stem cell transplantation

• After autologous or allogeneic hematopoietic stem cell transplantation, patients need essentially all vaccines repeated

Guidelines

• DTaP-HiB-IPV: 6 to 12 months after transplant
  • Diphtheria: 3 doses one month apart
  • Tetanus: 3 doses one month apart
  • Pertussis: 1 dose
  • Haemophilus influenzae type b: 3 doses 4 weeks apart
  • Polio (inactivate): 3 doses one month apart
• Hepatitis B: 6 to 12 months after transplant
  • Doses at 0, 1, and 6 months using high dose (40 μg)
  • Monitor HBsAb titres annually
• Influenza: annually
• Pneumococcal C-13 (Prevnar): 3 to 6 months after transplant
  • 3 doses 4 weeks apart
• Pneumococcal P-23 (Pneumovax): 6 to 12 months after last dose of C-13
  • 1 dose with a booster after 12 months
  • If GVHD, give an extra dose of C-13 and delay P-23 until GVHD resolved
• Meningococcal conjugate (quadrivalent): 6 months
  • 1 dose
  • If given before 6 months, will need another after 6 months and at least 2 months after the first
• Live vaccines (varicella, MMR, and yellow fever) at least 24 months after transplant, as long as no chronic GVHD, immunosuppression has been stopped for at least 3 months, and no active underlying disease
  • If receiving IVIg, delay MMR and varicella vaccines until 8 to 11 months after last dose
  • Check titres after second dose of MMR or varicella
• Contraindicated:
  • Live herpes zoster vaccine
  • BCG
  • MMRV
  • Rotavirus
  • Smallpox
  • Live typhoid
  • Live influenza (not recommended)

Sample Schedule

Immunization	Comments	Time post-transplant (months)
		6	7	8	10	12	14	18	24
DTaP Hib IPV (Pediacel)	Diptheria, tetanus, pertussis, polio, and Haemophilus influenzae type b	X	X	X				X
Hepatitis B	High-dose vaccine; monitor HBsAb titres annually	X	X			X
Pneumococcal C-13 (Prevnar)		X	X	X
Pneumococcal P-23 (Pneumovax)							X
Meningococcal conjugate (Menactra)		X		X
Influenza (inactivated)		Annually
Varicella	Only given if no titres at 24 months. Give extra dose 3 months later if no seroconversion.							X
MMR	Only given if no titres at 24 months. Give extra dose 3 months later if no seroconversion.							X
HPV	Ages 9 to 26 years, and possibly older	X		X		X
Herpes zoster recombinant inactivated (Shingrix)	Two doses at least one month apart
Hepatitis A	If risks present or travel planned	X				X
Cholera/traveller's diarrhea (inactivated)	If indicated	at least 6 months
Typhoid (inactivated)	If indicated	at least 6 months
Japanese encephalitis	If indicated	at least 6 months
Meningococcal B	If indicated by risk factors such as funtional hyposplenia	at least 6 months
Rabies	If indicated	at least 6 months

Further Reading

• Canadian Immunization Guide: Hematopoietic stem cell transplantation (HSCT) - autologous or allogeneic