UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Immunizations in hematopoietic cell transplant candidates and recipients

Author
Patricia L Hibberd, MD, PhD
Section Editor
Michael Boeckh, MD
Deputy Editor
Anna R Thorner, MD

INTRODUCTION

Prevention of infection is of paramount importance to the ever-increasing population of patients who have impaired immunity, such as those who have undergone hematopoietic cell transplantation (HCT). Infection in these patients often results in excessive morbidity and mortality, and antimicrobial therapy is typically less effective than in the immunocompetent host [1]. Although immunization appears to be an obvious way to prevent infection, many patients with impaired immunity are unable to mount a protective immune response to active vaccination. Furthermore, immunization with live virus vaccines may result in unchecked proliferation of attenuated strains.

The rationale for immunizing patients who have undergone HCT will be reviewed here. Issues related to immunizations in patients who have had or are waiting for a solid organ transplant, who have undergone chemotherapy for treatment of hematologic malignancies or solid tumors, or who have other immunocompromising conditions, including HIV infection, and in healthy adults and healthcare workers are discussed separately. (See "Immunizations in solid organ transplant candidates and recipients" and "Immunizations in patients with cancer" and "Immunizations in HIV-infected patients" and "Approach to immunizations in healthy adults" and "Immunizations for health care providers".)

Other issues related to infections in HCT recipients are reviewed separately. (See "Evaluation for infection before hematopoietic cell transplantation" and "Overview of infections following hematopoietic cell transplantation" and "Prevention of infections in hematopoietic cell transplant recipients" and "Prevention of viral infections in hematopoietic cell transplant recipients" and "Prophylaxis of invasive fungal infections in adult hematopoietic cell transplant recipients" and "Prophylaxis of infection during chemotherapy-induced neutropenia in high-risk adults".)

RISK OF INFECTION

The risk of acquiring infection and the inability to prevent infection by immunization are directly related to the patient's "net state of immunosuppression" or severity of disease. The greater the degree of immunosuppression, the less likely the patient is to respond to immunization. Although certain vaccines provide some benefit to the immunocompromised patient, an adequate response cannot be assumed. Successful protection of the immunocompromised adult may require the use of vaccines and/or passive immunization (ie, immune globulin) as well as adjunctive measures, such as antiviral drug prophylaxis during influenza A outbreaks. (See "Prevention of seasonal influenza with antiviral drugs in adults" and "Seasonal influenza in children: Prevention and treatment with antiviral drugs", section on 'Chemoprophylaxis'.)

The degree of immunosuppression after hematopoietic cell transplant (HCT) varies with the type of transplant.

                               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Nov 17 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Hibberd PL, Rubin RH. Approach to immunization in the immunosuppressed host. Infect Dis Clin North Am 1990; 4:123.
  2. 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.
  3. Berger M, Figari O, Bruno B, et al. Lymphocyte subsets recovery following allogeneic bone marrow transplantation (BMT): CD4+ cell count and transplant-related mortality. Bone Marrow Transplant 2008; 41:55.
  4. Talmadge JE. Lymphocyte subset recovery following allogeneic bone marrow transplantation: CD4(+)-cell count and transplant-related mortality. Bone Marrow Transplant 2008; 41:19.
  5. Kim DH, Sohn SK, Won DI, et al. Rapid helper T-cell recovery above 200 x 10 6/l at 3 months correlates to successful transplant outcomes after allogeneic stem cell transplantation. Bone Marrow Transplant 2006; 37:1119.
  6. Ljungman P, Cordonnier C, de Bock R, et al. Immunisations after bone marrow transplantation: results of a European survey and recommendations from the infectious diseases working party of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 1995; 15:455.
  7. Henning KJ, White MH, Sepkowitz KA, Armstrong D. A national survey of immunization practices following allogeneic bone marrow transplantation. JAMA 1997; 277:1148.
  8. Centers for Disease Control and Prevention, Infectious Disease Society of America, American Society of Blood and Marrow Transplantation. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Recomm Rep 2000; 49:1.
  9. Ljungman P, Engelhard D, de la Cámara R, et al. Vaccination of stem cell transplant recipients: recommendations of the Infectious Diseases Working Party of the EBMT. Bone Marrow Transplant 2005; 35:737.
  10. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.
  11. Parkkali T, Olander RM, Ruutu T, et al. A randomized comparison between early and late vaccination with tetanus toxoid vaccine after allogeneic BMT. Bone Marrow Transplant 1997; 19:933.
  12. Small TN, Zelenetz AD, Noy A, et al. Pertussis immunity and response to tetanus-reduced diphtheria-reduced pertussis vaccine (Tdap) after autologous peripheral blood stem cell transplantation. Biol Blood Marrow Transplant 2009; 15:1538.
  13. Ljungman P, Wiklund-Hammarsten M, Duraj V, et al. Response to tetanus toxoid immunization after allogeneic bone marrow transplantation. J Infect Dis 1990; 162:496.
  14. Hammarström V, Pauksen K, Björkstrand B, et al. Tetanus immunity in autologous bone marrow and blood stem cell transplant recipients. Bone Marrow Transplant 1998; 22:67.
  15. Lum LG, Munn NA, Schanfield MS, Storb R. The detection of specific antibody formation to recall antigens after human bone marrow transplantation. Blood 1986; 67:582.
  16. Nordøy T, Husebekk A, Aaberge IS, et al. Humoral immunity to viral and bacterial antigens in lymphoma patients 4-10 years after high-dose therapy with ABMT. Serological responses to revaccinations according to EBMT guidelines. Bone Marrow Transplant 2001; 28:681.
  17. Ljungman P, Duraj V, Magnius L. Response to immunization against polio after allogeneic marrow transplantation. Bone Marrow Transplant 1991; 7:89.
  18. Pauksen K, Hammarström V, Ljungman P, et al. Immunity to poliovirus and immunization with inactivated poliovirus vaccine after autologous bone marrow transplantation. Clin Infect Dis 1994; 18:547.
  19. Engelhard D, Handsher R, Naparstek E, et al. Immune response to polio vaccination in bone marrow transplant recipients. Bone Marrow Transplant 1991; 8:295.
  20. Atkinson K, Storb R, Prentice RL, et al. Analysis of late infections in 89 long-term survivors of bone marrow transplantation. Blood 1979; 53:720.
  21. Winston DJ, Schiffman G, Wang DC, et al. Pneumococcal infections after human bone-marrow transplantation. Ann Intern Med 1979; 91:835.
  22. Cordonnier C, Bernaudin JF, Bierling P, et al. Pulmonary complications occurring after allogeneic bone marrow transplantation. A study of 130 consecutive transplanted patients. Cancer 1986; 58:1047.
  23. Aucouturier P, Barra A, Intrator L, et al. Long lasting IgG subclass and antibacterial polysaccharide antibody deficiency after allogeneic bone marrow transplantation. Blood 1987; 70:779.
  24. Sheridan JF, Tutschka PJ, Sedmak DD, Copelan EA. Immunoglobulin G subclass deficiency and pneumococcal infection after allogeneic bone marrow transplantation. Blood 1990; 75:1583.
  25. Hoyle C, Goldman JM. Life-threatening infections occurring more than 3 months after BMT. 18 UK Bone Marrow Transplant Teams. Bone Marrow Transplant 1994; 14:247.
  26. Rege K, Mehta J, Treleaven J, et al. Fatal pneumococcal infections following allogeneic bone marrow transplant. Bone Marrow Transplant 1994; 14:903.
  27. Winston DJ, Ho WG, Schiffman G, et al. Pneumococcal vaccination of recipients of bone marrow transplants. Arch Intern Med 1983; 143:1735.
  28. Vance E, George S, Guinan EC, et al. Comparison of multiple immunization schedules for Haemophilus influenzae type b-conjugate and tetanus toxoid vaccines following bone marrow transplantation. Bone Marrow Transplant 1998; 22:735.
  29. Engelhard D, Cordonnier C, Shaw PJ, et al. Early and late invasive pneumococcal infection following stem cell transplantation: a European Bone Marrow Transplantation survey. Br J Haematol 2002; 117:444.
  30. Giebink GS, Warkentin PI, Ramsay NK, Kersey JH. Titers of antibody to pneumococci in allogeneic bone marrow transplant recipients before and after vaccination with pneumococcal vaccine. J Infect Dis 1986; 154:590.
  31. Patel SR, Ortín M, Cohen BJ, et al. Revaccination with measles, tetanus, poliovirus, Haemophilus influenzae type B, meningococcus C, and pneumococcus vaccines in children after hematopoietic stem cell transplantation. Clin Infect Dis 2007; 44:625.
  32. Kumar D, Humar A, Plevneshi A, et al. Invasive pneumococcal disease in adult hematopoietic stem cell transplant recipients: a decade of prospective population-based surveillance. Bone Marrow Transplant 2008; 41:743.
  33. Kumar D, Chen MH, Welsh B, et al. A randomized, double-blind trial of pneumococcal vaccination in adult allogeneic stem cell transplant donors and recipients. Clin Infect Dis 2007; 45:1576.
  34. Meisel R, Kuypers L, Dirksen U, et al. Pneumococcal conjugate vaccine provides early protective antibody responses in children after related and unrelated allogeneic hematopoietic stem cell transplantation. Blood 2007; 109:2322.
  35. Cordonnier C, Labopin M, Chesnel V, et al. Randomized study of early versus late immunization with pneumococcal conjugate vaccine after allogeneic stem cell transplantation. Clin Infect Dis 2009; 48:1392.
  36. Cordonnier C, Ljungman P, Juergens C, et al. Immunogenicity, safety, and tolerability of 13-valent pneumococcal conjugate vaccine followed by 23-valent pneumococcal polysaccharide vaccine in recipients of allogeneic hematopoietic stem cell transplant aged ≥2 years: an open-label study. Clin Infect Dis 2015; 61:313.
  37. Black SB, Shinefield HR, Fireman B, et al. Efficacy in infancy of oligosaccharide conjugate Haemophilus influenzae type b (HbOC) vaccine in a United States population of 61,080 children. The Northern California Kaiser Permanente Vaccine Study Center Pediatrics Group. Pediatr Infect Dis J 1991; 10:97.
  38. Guinan EC, Molrine DC, Antin JH, et al. Polysaccharide conjugate vaccine responses in bone marrow transplant patients. Transplantation 1994; 57:677.
  39. Barra A, Cordonnier C, Preziosi MP, et al. Immunogenicity of Haemophilus influenzae type b conjugate vaccine in allogeneic bone marrow recipients. J Infect Dis 1992; 166:1021.
  40. Kim DK, Bridges CB, Harriman KH, et al. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older--United States, 2015. MMWR Morb Mortal Wkly Rep 2015; 64:91.
  41. Cohn AC, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62:1.
  42. Aschan J, Ringdén O, Ljungman P, et al. Influenza B in transplant patients. Scand J Infect Dis 1989; 21:349.
  43. Ljungman P, Andersson J, Aschan J, et al. Influenza A in immunocompromised patients. Clin Infect Dis 1993; 17:244.
  44. Whimbey E, Elting LS, Couch RB, et al. Influenza A virus infections among hospitalized adult bone marrow transplant recipients. Bone Marrow Transplant 1994; 13:437.
  45. Whimbey E, Champlin RE, Couch RB, et al. Community respiratory virus infections among hospitalized adult bone marrow transplant recipients. Clin Infect Dis 1996; 22:778.
  46. Engelhard D, Nagler A, Hardan I, et al. Antibody response to a two-dose regimen of influenza vaccine in allogeneic T cell-depleted and autologous BMT recipients. Bone Marrow Transplant 1993; 11:1.
  47. Machado CM, Cardoso MR, da Rocha IF, et al. The benefit of influenza vaccination after bone marrow transplantation. Bone Marrow Transplant 2005; 36:897.
  48. Avetisyan G, Aschan J, Hassan M, Ljungman P. Evaluation of immune responses to seasonal influenza vaccination in healthy volunteers and in patients after stem cell transplantation. Transplantation 2008; 86:257.
  49. Ilan Y, Nagler A, Adler R, et al. Adoptive transfer of immunity to hepatitis B virus after T cell-depleted allogeneic bone marrow transplantation. Hepatology 1993; 18:246.
  50. Nagler A, Ilan Y, Adler R, et al. Successful immunization of autologous bone marrow transplantation recipients against hepatitis B virus by active vaccination. Bone Marrow Transplant 1995; 15:475.
  51. Jaffe D, Papadopoulos EB, Young JW, et al. Immunogenicity of recombinant hepatitis B vaccine (rHBV) in recipients of unrelated or related allogeneic hematopoietic cell (HC) transplants. Blood 2006; 108:2470.
  52. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1999; 48:1.
  53. Hata A, Asanuma H, Rinki M, et al. Use of an inactivated varicella vaccine in recipients of hematopoietic-cell transplants. N Engl J Med 2002; 347:26.
  54. Redman RL, Nader S, Zerboni L, et al. Early reconstitution of immunity and decreased severity of herpes zoster in bone marrow transplant recipients immunized with inactivated varicella vaccine. J Infect Dis 1997; 176:578.
  55. Stadtmauer EA, Sullivan KM, Marty FM, et al. A phase 1/2 study of an adjuvanted varicella-zoster virus subunit vaccine in autologous hematopoietic cell transplant recipients. Blood 2014; 124:2921.
  56. Clinicaltrials.gov. Study to evaluate efficacy, safety, and immunogenicity of GlaxoSmithKline (GSK) Biologicals' herpes zoster vaccine GSK1437173A. https://clinicaltrials.gov/ct2/show/NCT01610414?term=GSK+varicella+autologous&rank=1 (Accessed on September 11, 2015).
  57. Machado C, Goncalves F, Pannuti C, et al. Measles in BMT recipients during an outbreak in Sao Paulo, Brazil. ICAAC abstract LB-24 Toronto, Canada, 1997.
  58. Ljungman P, Fridell E, Lönnqvist B, et al. Efficacy and safety of vaccination of marrow transplant recipients with a live attenuated measles, mumps, and rubella vaccine. J Infect Dis 1989; 159:610.
  59. Pauksen K, Duraj V, Ljungman P, et al. Immunity to and immunization against measles, rubella and mumps in patients after autologous bone marrow transplantation. Bone Marrow Transplant 1992; 9:427.
  60. King SM, Saunders EF, Petric M, Gold R. Response to measles, mumps and rubella vaccine in paediatric bone marrow transplant recipients. Bone Marrow Transplant 1996; 17:633.
  61. Han CS, Miller W, Haake R, Weisdorf D. Varicella zoster infection after bone marrow transplantation: incidence, risk factors and complications. Bone Marrow Transplant 1994; 13:277.
  62. Marin M, Güris D, Chaves SS, et al. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007; 56:1.
  63. Sauerbrei A, Prager J, Hengst U, et al. Varicella vaccination in children after bone marrow transplantation. Bone Marrow Transplant 1997; 20:381.
  64. Bhalla P, Forrest GN, Gershon M, et al. Disseminated, persistent, and fatal infection due to the vaccine strain of varicella-zoster virus in an adult following stem cell transplantation. Clin Infect Dis 2015; 60:1068.
  65. Centers for Disease Control and Prevention (CDC). FDA approval of an extended period for administering VariZIG for postexposure prophylaxis of varicella. MMWR Morb Mortal Wkly Rep 2012; 61:212.
  66. McLean HQ, Fiebelkorn AP, Temte JL, et al. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62:1.
  67. Harrington RD, Hooton TM, Hackman RC, et al. An outbreak of respiratory syncytial virus in a bone marrow transplant center. J Infect Dis 1992; 165:987.
  68. Khanna N, Widmer AF, Decker M, et al. Respiratory syncytial virus infection in patients with hematological diseases: single-center study and review of the literature. Clin Infect Dis 2008; 46:402.
  69. Small TN, Casson A, Malak SF, et al. Respiratory syncytial virus infection following hematopoietic stem cell transplantation. Bone Marrow Transplant 2002; 29:321.
  70. Boeckh M, Berrey MM, Bowden RA, et al. Phase 1 evaluation of the respiratory syncytial virus-specific monoclonal antibody palivizumab in recipients of hematopoietic stem cell transplants. J Infect Dis 2001; 184:350.
  71. Chemaly RF, Ghosh S, Bodey GP, et al. Respiratory viral infections in adults with hematologic malignancies and human stem cell transplantation recipients: a retrospective study at a major cancer center. Medicine (Baltimore) 2006; 85:278.
  72. Kulkarni S, Powles R, Singhal S, et al. Late pneumococcal infections in bone marrow transplant recipients: is penicillin prophylaxis inadequate? (abstract). Blood 1998; 92:320a.
  73. Wimperis JZ, Brenner MK, Prentice HG, et al. Transfer of a functioning humoral immune system in transplantation of T-lymphocyte-depleted bone marrow. Lancet 1986; 1:339.
  74. Wimperis JZ, Brenner MK, Prentice HG, et al. B cell development and regulation after T cell-depleted marrow transplantation. J Immunol 1987; 138:2445.
  75. Gottlieb DJ, Cryz SJ Jr, Furer E, et al. Immunity against Pseudomonas aeruginosa adoptively transferred to bone marrow transplant recipients. Blood 1990; 76:2470.
  76. Vavassori M, Maccario R, Moretta A, et al. Restricted TCR repertoire and long-term persistence of donor-derived antigen-experienced CD4+ T cells in allogeneic bone marrow transplantation recipients. J Immunol 1996; 157:5739.
  77. Molrine DC, Guinan EC, Antin JH, et al. Donor immunization with Haemophilus influenzae type b (HIB)-conjugate vaccine in allogeneic bone marrow transplantation. Blood 1996; 87:3012.
  78. Storek J, Dawson MA, Lim LC, et al. Efficacy of donor vaccination before hematopoietic cell transplantation and recipient vaccination both before and early after transplantation. Bone Marrow Transplant 2004; 33:337.
  79. Molrine DC, Antin JH, Guinan EC, et al. Donor immunization with pneumococcal conjugate vaccine and early protective antibody responses following allogeneic hematopoietic cell transplantation. Blood 2003; 101:831.
  80. Parkkali T, Käyhty H, Hovi T, et al. A randomized study on donor immunization with tetanus-diphtheria, Haemophilus influenzae type b and inactivated poliovirus vaccines to improve the recipient responses to the same vaccines after allogeneic bone marrow transplantation. Bone Marrow Transplant 2007; 39:179.
  81. Brugger SA, Oesterreicher C, Hofmann H, et al. Hepatitis B virus clearance by transplantation of bone marrow from hepatitis B immunised donor. Lancet 1997; 349:996.
  82. Centers for Disease Control and Prevention (CDC). Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices--United States, 2013-2014. MMWR Recomm Rep 2013; 62:1.