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Vaccinations

Routine administration of vaccinations is vital for prevention of infectious complications in transplant recipients.

Transplant recipients may remain immunocompromised far beyond 2 years post-transplant, especially individuals with chronic graft-versus-host-disease (GVHD). Therefore, patients should be routinely revaccinated after transplant until they regain immune competence.

These vaccination recommendations are based on international consensus guidelines for preventing infectious complications among all transplant recipients and are recommended for both autologous and allogeneic HCT recipients. [1,2,3,4]

Use these charts to:
  • Become aware of the vaccinations transplant recipients need
  • Plan for administration of vaccines
These guidelines are also available in:
Vaccine
Recommended for use after HCT
Months post-HCT to initiate vaccine
Doses
Notes
COVID
Yes
3
3-4
  • Use the most current COVID vaccine (0, 1, 3, 5 months from initiation).
  • Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).
DTaP

(diphtheria tetanus pertussis vaccine)
Yes
6-12
3
  • “Pediatric” DTaP favored over Tdap (tetanus toxoid-reduced diphtheria-toxoid reduced acellular pertussis vaccine) for all ages.
  • DTaP is preferred; however, if only Tdap is available (for example, because DTaP is not licensed for adults), administer Tdap. Acellular pertussis vaccine is preferred, but the whole-cell pertussis vaccine should be used if it is the only pertussis vaccine available.
  • Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).
Hepatitis B
Yes
6-12
3-4
  • 4 double-doses of Engerix for adults (0, 1, 2, 6 months from initiation) or 4 standard doses of Heplisav-B (0, 1, 2, 6 months from initiation). Children receive 3 standard doses of Engerix.
  • Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).
Hib
Yes
6-12
3
Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).
HPV9
Yes
6-12
3
  • Age 9-26 (up to age 45 with shared medical decision-making).
  • Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).
Inactivated influenza (high dose)
Yes
4-6
2+
  • In flu season. Two doses of high-dose IIV4 at least for the first post-transplant flu season.
  • For children <9 years of age, two doses are recommended yearly between transplant and 9 years of age.
  • Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).
IPV
—
6-12
3
Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).
MCV4
Yes
6-12
2
Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).
MMR
Yes
24
2
All ages get 2 doses, 1 month apart as a combination vaccine. Do not give unless also >1 year off IST and <8 months since last dose of IVIG.

Not recommended <24 months post-HCT, in patients with active GVHD, and in patients on immune suppression.

Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).
PCV20
Yes
3-6
3-4 based on titers
  • 3 doses, each 2 months apart. If the first dose is at 3 months, then give a fourth dose at least 6 months after the third dose.
  • Following the primary series of three PCV doses, a dose of the 23-valent polysaccharide pneumococcal vaccine (PPSV23) to broaden the immune response might be given. For patients with chronic GVHD who are likely to respond poorly to PPSV23, a fourth dose of the PCV should be considered instead of PPSV23.
  • Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).
SHINGRIX (Zoster)
Yes
12
2
  • Age ≥8 years, at least 1-year post-transplant and at least 8 months of IST without GVHD flare ups (autologous recipients generally have also completed maintenance immunotherapy which prolongs the duration of acyclovir prophylaxis). Only give if the patient is VZV seropositive (at least 8 months off IVIG); if seronegative, should instead first complete live attenuated varicella series per above recommendation.
  • Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).
Varicella
Yes
24
2
  • If VZV seronegative after transplant. Can be given as combined MMR-V.
  • Depends on the overall level of basic numeric immune reconstitution (rule of thumb CD4>200/microliter, CD19>20/microliter and not needing immunoglobulin replacement therapy because IgG levels are adequately well maintained).

References

  1. Rotz SJ, Bhatt NS, Hamilton BK, et al. (2024). International recommendations for screening and preventative practices for long-term survivors of transplantation and cellular therapy: Transplantation and Cellular Therapy, 30(4) 349-385. DOI: 10.1016/j.jtct.2023.12.001.
  2. Carpenter P, Boeckh M, Deeg J, et al. (2023). Long-term follow-up after hematopoietic stem cell l transplant general guidelines for referring physicians. Fred Hutchinson Cancer Center. Access
  3. Tomblyn M, Chiller T, Einsele H, et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009; 15: 1143-1238. DOI: 10.1016/j.bbmt.2009.06.019 
  4. Ljungman P, Cordonnier C, Einsele H, et al. Vaccination of hematopoietic cell transplant recipients. Bone Marrow Transplant. 2009; 44: (8) 521-526. DOI: 10.1038/bmt.2009.263.