Vaccination of the Stem Cell Transplant Recipient and the Hematologic Malignancy Patient

Abstract

Patients with hematologic malignancy or those who undergo hematopoietic stem cell transplantation experience variable degrees of immunosuppression, dependent on underlying disease, therapy received, time since transplant, and complications, such as graft-versus-host disease. Vaccination is an important strategy to mitigate onset and severity of certain vaccine-preventable illnesses, such as influenza, pneumococcal disease, or varicella zoster infection, among others. This article highlights vaccines that should and should not be used in this patient population and includes general guidelines for timing of vaccination administration and special considerations in the context of newer therapies, recent vaccine developments, travel, and considerations for household contacts.

Keywords: Cancer; Hematologic; Stem cell transplant; Vaccines.

Figure 1.

Immunization schedule for SCT recipients ¹ Inactivated influenza vaccines: For children < 9 years of age, two doses of IIV one month apart. In elderly patients (≥ 65 years of age) consider the following if readily available: High dose (HD-IIV3; Fluzone) or Adjuvanted (aIIV3; Fluad). *May administer vaccine at 4months if widespread influenza in community. ²Pneumococcal conjugate vaccine: ** Give fourth dose of PCV-13 if GVHD requiring immunosuppression. For all others, PPSV-23 booster (23 valent polysaccharide vaccine) is given at one year. ³Tetanus, diphtheria, acellular pertussis vaccination: Various combinations and doses of vaccines exist, including DTaP, DT, Tdap, Td. Capital letters indicate higher toxoid or antigen amounts. GiveDTaP × 3 doses to all children ≤ 7 years; and can consider for all patients irrespective of age, though DTaP is only license in children < 7 years of age. Alternatively, can give 3 doses of Tdap, or one dose of Tdap followed by 2 doses of Td. Among Tdap vaccines, Boostrix contains higher pertussis antigen than Adacel. Boostrix is preferred in adult’s ≥ 65 years. ⁴Recombinant Hepatitis B: check serology after 3 doses, if negative anti-Hbs titer, re-vaccinate with 3 dose series; alternative, one dose booster of either high antigen dose vaccine or standard dose and re-check anti-Hbs titer; if vaccinating with combined Hepatitis A and B vaccine product, must still check anti-Hbs titer, and re-vaccinate with Hepatitis B vaccine if negative. ⁵Measles, mumps, rubella: If measles antibody negative, vaccinate with 2 doses at least one month apart. ⁶Recommended for use in VZV seronegative patients. See text for data on recombinant zoster vaccine (Shingrix) in auto transplant recipients. ⁷MCV-4: Recommended for persons aged 11–18 years, with a booster at 16–18 years. Meningococcal B vaccines should additionally be administered to SCT recipients aged 10–25 years with at risk conditions (asplenia, terminal complement deficiency, laboratory worker, travel, outbreak). ⁸HPV: Now available as 9-valent vaccine. Vaccinate in patients 9–26 years of age; FDA has recently expanded indicated age range to up to 45 years.