Timing of vaccines for allogeneic hematopoietic cell transplant recipients

Vaccine	Recommendation	Number of doses	Comments
3 to 6 months post-transplant
COVID-19 (SARS-CoV-2) vaccine	All HCT recipients ≥6 months of age^[1]	2 or 3 (depending on vaccine formulation)
Pneumococcal conjugate vaccine-20 (PCV20)^*	All HCT recipients	3 doses (1 month apart) 4^th dose at 12 months	If PCV20 is not available: No GVHD: administer PPSV23 for the 4^th dose. GVHD: administer PCV10, 13, or 15 for the dose (the highest valency available).
6 to 12 months post-transplant
Influenza vaccine (inactivated)	All HCT recipients ≥6 months of age	1 dose (annually)	Can be given as early as 4 months if community outbreak. If given early, a second dose should be administered at least 4 weeks after initial dose to provide additional protection against influenza.
Tetanus, diphtheria, and pertussis vaccine	All HCT recipients	3 doses DTaP (1 to 3 months apart)	For patients ≥7 years of age, an alternative schedule includes 1 dose of Tdap followed by either 2 doses of DT or Td, with all doses spaced 1 to 3 months apart.
Haemophilus influenzae b conjugate vaccine	All HCT recipients	3 doses (1 month apart)
Polio-inactivated (inactivated poliovirus vaccine)	All HCT recipients	3 doses (1 to 3 months apart)
Meningococcal conjugate vaccine^¶	Age 11 to 18 years or other risk factors present (eg, asplenia, residing in or traveling to areas of hyperendemicity or epidemicity)	2 doses (4 to 5 years apart)
MenB vaccine^¶	Age 16 to 23 or other risk factors (eg, asplenia, residing or traveling to areas of hyperendemicity or epidemicity)	1 dose
Human papillomavirus vaccine	Age 9 to 26 years	2 to 3 doses^Δ
Respiratory syncytial virus	Age 60 years or older	1 dose	In the absence of efficacy and safety data with this vaccine in HCT recipients, balancing risk of significant disease in this population, we engage in shared decision making with our patients when deciding whether to administer this vaccine.
Hepatitis A vaccine	If risk factors present (eg, chronic liver disease, travel to endemic areas)	2 doses (6 months apart)
Mpox virus vaccine (non-replicating, modified vaccinia Ankara vaccine)	If risk factors present (eg, males who have sex with males and have multiple sex partners or a diagnosis of an STI in the past 6 months)	2 doses (1 month apart)
1 year post-transplant
Hepatitis B vaccine	All HCT recipients	3 doses (dosing intervals depend on the specific vaccine formulation used)	Can be administered as early as 6 months if necessary. We prefer to wait until 12 months when possible to optimize immunity from vaccine. Test serology ≥1 month following the 3^rd dose to assess the response to vaccine.
RZV	HCT recipients who meet the following criteria: At least 12 months has passed since HCT Off immunosuppressive therapy No GVHD flares	2 doses (2 to 6 months apart)	Antiviral prophylaxis (eg, acyclovir) is also used to prevent herpes zoster early after transplant
≥2 years post-transplant
Measles, mumps, and rubella vaccine	HCT recipients who meet all of the following criteria: Measles and/or rubella seronegative No active GVHD Not receiving any immunosuppression Last dose of IVIG and other blood products^[2] was administered more than 8 to 11 months ago	2 doses (at least 4 weeks apart)
Varicella	HCT recipients who meet all of the following criteria: Varicella seronegative No active GVHD Not receiving any immunosuppression Last dose of IVIG and other blood products^[2] was administered more than 8 to 11 months ago	2 doses (4 to 8 weeks apart)

The table outlines the general timing of when to administer vaccines to allogeneic HCT recipients. Patients with GVHD or other complications may warrant a different timeline of vaccine administration.

COVID-19: coronavirus disease 2019; DTaP: diphtheria toxoid, tetanus toxoid, acellular pertussis; DT: diphtheria toxoid, tetanus toxoid; GVHD: graft-versus-host disease; HCT: hematopoietic cell transplant; IVIG: intravenous immunoglobulin; mRNA: messenger ribonucleic acid; PPSV: pneumococcal polysaccharide vaccine; RZV: recombinant zoster vaccine; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; STI: sexually transmitted infection; Tdap: tetanus toxoid, reduced diphtheria toxoid, and reduced acellular pertussis; Td: tetanus toxoid, reduced diphtheria toxoid.

* PCV20 formulation is preferred. However, PCV15 or another pneumococcal conjugate vaccine formulation is a reasonable alternative if PCV20 is not available.

¶ A pentavalent meningococcal conjugate vaccine (MenABCWY) is also available in the United States. If immunization against all five meningococcal groups is indicated, the pentavalent meningococcal conjugate vaccine (MenABCWY) can be administered, if available.

Δ Dosing schedule differs based on initial age of vaccination. Refer to UpToDate content on HPV vaccination for details.

References:

Bastidas A, de la Serna J, El Idrissi M, et al. Effect of recombinant zoster vaccine on incidence of herpes zoster after autologous stem cell transplantation: A randomized clinical trial. JAMA 2019; 322:123.
Kambo M, Shah MK. Vaccination of the stem cell transplant (SCT) recipient and the hematologic malignancy patient. Infect Dis Clin North Am 2019; 33:593.

With additional data from:

Use of COVID-19 vaccines in the United States. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html (Accessed on March 13, 2024).
Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clinical Infectious Diseases 2013; 58:e44.
Timing and spacing of immunobiologics: General best practice guidelines for immunization. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html (Accessed on March 13, 2024).

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Timing of vaccines for allogeneic hematopoietic cell transplant recipients