Vaccination after hematopoietic stem cell transplantation

• Following hematopoietic stem cell transplantation, the immune system is considered to have been never immunized
  • Recipients need essentially all (allogeneic) or most (autologous) routine immunizations following transplantation
  • Recipients recipients respond poorly to polysaccharide vaccines
  • Titres can be checked to confirm immune response and direct further revaccination
• Most inactivated vaccines are started around 6 months after vaccination
• Most live vaccines can be given after 24 months, including univalent varicella, MMR, and yellow fever faccines
• Close contacts should also ensure vaccinations are up to date

Inactivated Vaccines

• Recommended post-transplant
  • 3-9 months: conjugate pneumococcal vaccine, 3 doses 1 month apart
  • 4-6 months: annual inactivated influenza vaccine
  • 6 months: quadrivalent meningococcal vaccine, 1 dose (or a second dose after 8 weeks if first is given before 6 months)
  • 6 to 12 months:
    • Polysaccharide pneumococcal vaccine: 1 dose at least 6 to 12 months after conjugate vaccine, with a booster 12 months later
      • Delay if ongoing GVHD, and given a fourth dose of Pneu-C-13 instead
    • Diphtheria: 3 doses 1 month apart, with booster at 18 months
    • Pertussis: 1 dose (if given alone), with booster at 18 months
    • Inactivated polio: 3 doses 1 month apart, with booster at 18 months
    • Tetanus: 3 doses 1 month apart, with booster at 18 months
    • Hepatitis B: 3 doses (at 0, 1, and 6 months) followed by HBsAb titres and a booster if titre less than 10 IU/L
    • Haemophilus influenzae: 3 doses at least 4 weeks apart
  • Inactivated herpes zoster vaccine is not routinely indicated, but can be considered in those age 50 years and older
• Not routinely given, but no contraindications: hepatitis A, inactivated oral cholera, Japanese encephalititis, rabies, inactivated intramuscular typhoid, tick-borne encephalitis, and HPV

Live Vaccines

• Contraindicated vaccines include: BCG, live influenza vaccine, rotavirus, smallpox, oral typhoid, oral polio, live herpes zoster (Zostavax)
• Other live vaccines, including univalent varicella, yellow fever, and MMR, can be given starting at 24 months provided they are considered immunocompetent
• In other to receive live vaccines:
  • At least 24 months post-transplant
  • No ongoing graft-versus-host disease
  • No corticosteroids or other immunosuppressants for at least 3 months
  • No immunoglobulin in the past 8 to 11 months (except for yellow fever vaccine)
  • Assessed by primary team and considered immunocompetent
• Following immunization, check titres for varicella and MMR

Sample Schedule

Sample immunization schedule

	Vaccine	Months Post-Transplant									Notes
		6	7	8	10	12	14	18	24	26
Inactivated	DTaP-Hib-IPV	x	x	x				x
	Hepatitis B	x	x			x					booster if titre less than 10 IU/L
	Pneu-C-13	x	x	x
	Pneu-P-23						x			x
	Men-C-ACYW135	x		x
	Influenza	annually
	Hepatitis A	x				x					if travel or other risk present
	HPV	x		x		x					if recommended by age and sex
	Herpes zoster										if age ≥50 years
Live	Varicella								x		booster at 3 months if no seroconversion
	MMR								x