LEEDS TEACHING HOSPITALS TRUST
eClinical Guidelines Template
Guideline for Adult Patient Immunisation after
Haemopoietic Stem Cell Transplant
Guideline Detail
Ownership: Yorkshire Blood and Bone Marrow Transplant Service
Publication date: September 2011
Next Review date: September 2011
Status
Summary
Background: Patients require re-immunisation following haemopoietic stem
cell transplantation (HSCT) as they lose previous immunity to vaccine
preventable diseases and are more susceptible to infection.
Principles of Immunisation Post-HSCT: Patients are vaccinated according
to a schedule that is similar to that followed by a healthy but unimmunised
individual of the same age. They may need additional vaccines e.g. seasonal
influenza but in many cases live vaccines are contra-indicated.
Post-HSCT Schedule: Please see Page 3
Notes: A complete vaccination course will take 5 years to complete. The
vaccinations required may differ according to age and gender, guidance on
appropriate formulations is given.
Aims
To improve the delivery of vaccinations post HSCT and care of these patients
Objectives
 To explain the principle of giving vaccinations of patients post HSCT
 To give clear guidance regarding the timetable of vaccinations for
patients who have undergone HSCT
Background
Haemopoietic Stem Cell Transplantation
High doses of cytotoxic therapy, used against several malignancies, severely
impair the patient’s haemopoietic and immune system. The purpose of HSCT,
often referred to as “bone marrow transplant” is to reconstitute that system,
and thus restore immunity, red cell function and clotting functions. The
transplant may be a stored stem cell graft from the same patient
(“autologous”) or from a tissue matched donor (“allogeneic”).
In the case of allogeneic transplantation, the recipient is treated with
immunosuppressive therapy to aid acceptance and ongoing tolerance of the
graft. As the graft becomes established, the immunosuppressive therapy is
tapered and withdrawn.
Risk of Infection following HSCT
HSCT permits much stronger therapy against malignancy than would
otherwise be tolerable, and it also creates a beneficial “graft versus
malignancy” effect. However, immune reconstitution takes months to years
and is never entirely complete. In addition, especially following allogeneic
transplants, the patient may require additional immunosuppressive therapy.
This is started in order to treat the common HSCT complication known as
“graft versus host disease.” Additional and prolonged immunosuppression
renders the patient more susceptible to a variety of infections – to those
affecting the population at large and to some that are particular to this
situation.
This risk of infection can be minimised by:
-
Universal precautions (e.g. hand washing, catering, toilet hygiene etc)
Patient / parent education
Rapid access to medical care when illness occurs
Immunisation, which is the subject of the present document.
European and US consensus guidance on immunisation post-HSCT has been
issued and recently updated (Ljungman P et al 2009). The present document
translates this into a UK context by:
- outlining the general principles of immunisation post-HSCT
- suggesting a schedule
- explaining the use of specific vaccines
Principles of Immunisation Post-HSCT
1. People who have HSCT have in effect had their immune memory
wiped out by their preceding cytotoxic therapy. Therefore they need,
not just boosters, but complete re-immunisation as appropriate to their
age and country of residence. In the UK this will be by adoption of the
NHS routine schedule.
2. Immune function recovers slowly and incompletely, which is why most
of these vaccines should be offered from about 12 months post HSCT.
Once started, the schedule is similar to that followed by a healthy but
unimmunised individual of the same age.
3. In addition, because of the immune impairment, some additional
vaccines are needed, especially against Streptococcus pneumoniae,
Haemophilus influenzae and seasonal influenza. These should
generally be started earlier, at 3 months post-treatment, because of the
specific vulnerability to these conditions. Conversely, some live
vaccines (e.g. BCG) may remain contraindicated long term.
4. It is important for the patient’s surrounding family to be completely
immunised themselves, chiefly for the routine vaccines plus
occasionally some extras such as chickenpox, where available, to
“ring-protect” the individual.
5. Ideally the HSCT donor should have been fully immunised although
this is seldom feasible to arrange, particularly if the donor is unrelated.
6. The immunisations recommended here can usually be given routinely
in primary care under normal conditions. However, if the patient’s
clotting ability is impaired, standard intra-muscular injection may cause
serious bruising. Confirm that the platelet count is at least 100 x109/L,
or inject subcutaneously when feasible, or refer to the hospital
consultant haematologist.
7. Local Patient Group Directions (PGDs) may not cover all of the
immunisations recommended here. If not, nurses could administer
them under Patient Specific Directions (PSD) or individual prescription
instead.
These guidelines do not describe contractual or remuneration aspects of such
immunisations. But in general, where they are not covered by existing local
immunisation service agreements, they should be encompassed by the
agreements for primary care prescribing of a hospital specialist’s individual
recommendation.
These guidelines do not cover immunisations required for foreign travel and
specific advice, to supplement routine advice, should be sought from the
haematology service.
Management-Post HSCT Immunisation Schedule
The following schedule is suggested; but because individual treatment and
remission patterns are so variable, the hospital consultant will always confirm
IF there are any changes, otherwise please follow the suggested plan.
Although the schedule refers to trade names of some vaccines, it should be
understood to apply to any generic or trade equivalent licensed for UK use.
Note that available formulations not infrequently change.
Immunisation Schedule & timing post HSCT
6 months:
Haemophilus influenzae with Neisseria meningitis group C (e.g. Mentorix )
Streptococcus pneumoniae PCV i.e Prevenar -13 (see Note 2)
Seasonal influenza vaccine (may require two doses) and annually thereafter
(see Note 3)
8 months:
Meningococcal A, C, W135, and Y conjugate vaccine (“Quad conjugate”) (e.g.
Menveo - see Note 4)
Seasonal influenza vaccine
Streptococcus pneumoniae PPV i.e Pneumovax II (see Note 2)
12 months:
Diphtheria-tetanus-pertussis-poliomyelitis (Dip-tet-pert-polio) (see Note 5)
Human Papilloma Virus (HPV) (eg Cervarix) for women born post 1985
(Note 6)
13 months:
Dip-tet-pert-polio
HPV (see note 6)
15 months:
Dip-tet-pert-polio
18 months:
HPV ( see note 6)
24 months:
MMR (live vaccine, see Note 7)
27 months:
MMR (live vaccine, see Note 7)
2½ years:
Dip-tet-polio
5½ years:
Dip-tet-polio
Notes
1. A full re-immunisation course will take five years to complete for an adult.
Advise the patient that over that period, evolution of individual condition or
expert guidance (on HSCT, or on immunisation in general) may well
supersede the initial recommendation. In particular, the duration of response
and hence the need for boosters is not yet fully established.
2. Streptococcus Pneumoniae
Two vaccines are in common use:
PCV: Pneumococcal polysaccharide from 13 capsular types of pneumococci
conjugate vaccine (adsorbed) (e.g. Prevenar-13). This vaccine is conjugated
to protein.
PPV: Pneumococcal polysaccharide from 23 capsular types of pneumococci
vaccine (e.g. Pneumovax II)
Schedule: PCV followed, after two months, by one dose of PPV.
3. Influenza: if the 3 month post-HSCT mark is reached between March and
August, defer until the new season’s vaccine arrives. Give two doses for the
first winter season.
4. Quad (ACW135Y) conjugate vaccine: can be given one month after a
previous vaccination against Meningococcus C. It may be practical to wait two
months so as to coincide with any second dose of pneumococcal vaccination.
5. Dip-tet-polio:
Schedule: The first three doses should be of Repevax, with boosters of
Revaxis.
6. HPV: women born 1985 or later are usually eligible for HPV until they pass
the age of 18; but post-HSCT it may be offered beyond that age. However
women born before 1985, and men, are not eligible. Three doses are needed,
ideally with a one month interval between first and second, and a five month
interval between second and third (e.g. Cervarix).
7. MMR: This is a live vaccine, so extra care is needed. Defer if the patient is
immunosuppressed or suffering from graft-versus-host disease. If in any
doubt, contact the transplant consultant haematologist.
Vaccines contra-indicated post-HSCT:
Yellow Fever, BCG, Heaf / Mantoux, Smallpox, Chickenpox, oral polio
If an indication for these appears to exist, discuss with the hospital consultant
how the patient’s risk might be otherwise reduced. For instance it may help to
“ring-immunise” the household contacts.
No particular need: Hepatitis A & Hepatitis B
Patients post-HSCT in general are not at heightened risk of those conditions,
and do not need immunising. But individuals who happen to fall into a risk
category can be immunised on the standard schedule from 12 months postHSCT. Travel vaccinations are not covered by this document – patients
should discuss travel plans with the transplant consultant haematologist.
Audit and Monitoring Compliance
Patients should ideally have a hand held record from the GP so that each
vaccination they have is recorded. Vaccination status will be reviewed at the
haematology clinic. An audit will be performed to see if patients are being
vaccinated according to these guidelines.
Provenance:
Author name (s)/ Post and addresses
1. Dr. Maria Gilleece, Consultant Clinical Haematologist, Yorkshire Blood and
Bone Marrow Transplant Centre, Bexley Wing, St. James University Hospital
2. Dr. Graham Sutton, Consultant in Communicable Disease Control, Health
Protection Agency, Seacroft Hospital.
3. Elizabeth O’Dowd, Medical Student, University of Leeds
4. Suzanne Liebersbach, Kay Kendall Leukaemia Fund “Long Term Followup” Clinical Nurse Specialist, Yorkshire Blood and Bone Marrow Transplant
Centre, Bexley Wing, St. James University Hospital
Clinical condition: Post-HSCT
Target patient group: Patients who have undergone HSCT
Target professional group: GP’s and other healthcare professionals
Adapted From: Ljungman P et al 2009. Guidelines: vaccination of
hematopoietic cell transplant recipients. Bone Marrow Transplantation 44:
521-526
Evidence Base:
References and Evidence levels:
Guidelines: C- Expert Consensus
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D.Leeds consensus. (where no national guidance exists or there is wide
disagreement with a level C recommendation or where national guidance documents
contradict each other)
1. Ljungman P et al 2009. Guidelines: vaccination of hematopoetic cell
transplant recipients. Bone Marrow Transplantation 44: 521-526
2. Tomblyn M, Chiller T et al 2009. Guidelines for Preventing Infectious
Complications among Hematopoietic Cell Transplantation Recipients: A
Global Perspective. Biology of Blood and Marrow Transplantation 15(10):
1143-1238.
3. Ljungman P and Small TN (2010). Vaccination of SCT recipients. Bone
Marrow Transplantation doi 10 1038/bmt 2010.274
4. Dept of Health 2007. Immunisation against infectious disease
Online at www.dh.gov.uk > public health > Green Book