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A transplant erases the protection built up by a lifetime of vaccinations, including childhood ones, and it has to be rebuilt. Published schedules exist, the vaccines are free at the point of use in the NHS, and the usual failure is that nobody writes the plan down. If you have had a transplant and have no written schedule, ask for one.
Why it is needed. The ECIL-7 guideline states that most transplant recipients lose their immunity to various pathogens as soon as the first months after transplant, irrespective of pre-transplant donor or recipient vaccinations, and that vaccination with inactivated vaccines is safe after transplantation and is an effective way to reinstate protection. The UK Green Book chapter 7 states that in patients who receive bone marrow transplants, any protective antibodies from exposure or vaccination prior to transplantation are likely to be lost and it is unclear whether the recipient acquires the donor's immunity, and that all such individuals should be considered for a re-immunisation programme after treatment is finished. The CDC's guidance explains the mechanism and the timescale: the ablation caused by the transplant will also gradually remove immune memory from previous vaccination, and antibody titres to vaccine-preventable diseases such as tetanus, poliovirus, measles, mumps, rubella and encapsulated bacteria decrease one to four years after autologous or allogeneic transplant if the recipient is not revaccinated. All three say the same thing: start again.
How well it works. ECIL-7 states that the response to vaccines in patients with transplants is usually lower than that in healthy individuals of the same age during the first months or years after transplant, but that it improves over time to become close to normal two to three years after the procedure.
Where the schedules differ, and it is a real difference. ECIL-7 recommends starting crucial vaccinations with inactivated vaccines from three months after transplant, irrespective of whether the patient has or has not developed graft-versus-host disease or received immunosuppressants, and adds that patients with GvHD have a higher risk of infection and are likely to benefit from vaccination. The US position is later: the CDC states that most non-live vaccines should be re-initiated six months after the transplant, that recipients should be revaccinated with three doses of Hib vaccine starting 6 to 12 months after successful transplant regardless of vaccination history or age, and that inactivated influenza vaccine should be administered beginning at least six months after transplant and annually thereafter for the life of the patient, with a dose as early as four months after transplant possible but a second dose then to be considered. So the two frameworks differ by roughly three months on when the programme starts, and ECIL is explicit that GvHD and immunosuppression are not reasons to wait while the US schedule is more conservative about timing.
The UK approach to the content of the schedule. The UK joint consensus statement from the British Society of Blood and Marrow Transplantation and Cellular Therapy, the Children's Cancer and Leukaemia Group and the British Infection Association states that national and international guidance recommends that transplant recipients are considered never vaccinated and offered a comprehensive course of revaccination, and sets out a pragmatic and standardised revaccination schedule for adult and paediatric recipients in the UK aligned to national vaccine availability and licensing. Treating a transplant recipient as never vaccinated is a clean rule that avoids the trap of assuming childhood doses still count. The full dose-by-dose UK schedule sits in that statement, which is not open access; it is cited here rather than reproduced, because reproducing a schedule from memory is exactly the error this file is written to avoid.
Live vaccines are the exception that needs judgement. ECIL-7 states that the use of live attenuated vaccines should be limited to specific situations because of the risk of vaccine-induced disease. The CDC states that varicella and MMR vaccines may be re-administered after transplant if 24 months have passed since transplant, the patient does not have graft-versus-host disease, and is considered immunocompetent, and that BCG, live attenuated influenza vaccine, typhoid vaccine and rotavirus vaccine are not recommended after transplant.
Specific vaccines worth knowing about. The CDC lists revaccination after transplant as indicated with pneumococcal vaccines, DTaP and Tdap, Hib, hepatitis A and B, inactivated polio, inactivated influenza, meningococcal conjugate and serogroup B vaccines in the relevant age or risk groups, and HPV vaccine for those aged 9 to 26, or 27 to 45 by shared decision. On shingles, the CDC states that recombinant zoster vaccine may be re-administered 6 to 12 months after an allogeneic transplant and 3 to 12 months after an autologous transplant, and that for precise timing this should optimally occur two months prior to cessation of prophylactic antiviral therapy. Recombinant zoster vaccine is not a live vaccine, which is why it is available to this group when the older live zoster vaccine was not. On yellow fever, the CDC states that if someone received yellow fever vaccine prior to a transplant, another dose should be re-administered after it, which matters for anyone who travels.
The interaction with immunoglobulin replacement. The CDC states that patients who have quantitative B-cell deficiencies and are receiving immunoglobulin therapy should not receive either non-live or live vaccines while receiving the immunoglobulin therapy because of concerns about effectiveness, and that patients on anti-B cell antibodies such as rituximab should wait at least six months. Anyone on both needs the two schedules planned together.
What is not resolved. Serological testing to confirm response is used variably and the guidelines do not agree on which titres to check or when. Revaccination after conventional chemotherapy without transplant is much less standardised than revaccination after transplant. And the commonest failure in practice is not a disagreement between guidelines but a handover gap: the transplant centre assumes the general practice will do it, the general practice assumes the centre has. A written plan, held by the patient, closes that gap.
Immunological memory lives in long-lived plasma cells and memory lymphocytes, populations that conditioning depletes and that a donor graft does not reliably reconstitute with the recipient's prior specificities. Protection must therefore be re-induced rather than recalled, which is why a full primary course is given rather than a booster, and why responses are poorer early, when the reconstituting repertoire is narrow and thymic output low, and improve over two to three years.
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Shares B-cell aplasia and low antibodies after CAR-T and bispecifics, and immunoglobulin replacement, Rebuilding an immune system: the timeline, lineage by lineage, Infection risk after transplant and cell therapy, phase by phase, and the prophylaxis that follows it, After a transplant or cell therapy: what to ask for and the tags rejuvenation, survivorship, transplant.
Shares Infection risk after transplant and cell therapy, phase by phase, and the prophylaxis that follows it, Graft-versus-host disease (GVHD) and graft-versus-leukaemia, After a transplant or cell therapy: what to ask for, Allogeneic stem cell transplantation and the tags rejuvenation, survivorship, transplant, immune.
Shares Who is supposed to be watching: EBMT, CIBMTR, FACT-JACIE, and what a survivor is actually offered, After a transplant or cell therapy: what to ask for, Autologous stem cell transplant (high-dose therapy), Allogeneic stem cell transplantation and the tags rejuvenation, survivorship, transplant.
Shares Rebuilding an immune system: the timeline, lineage by lineage, Infection risk after transplant and cell therapy, phase by phase, and the prophylaxis that follows it, Graft-versus-host disease (GVHD) and graft-versus-leukaemia, After a transplant or cell therapy: what to ask for and the tags rejuvenation, survivorship, transplant.
Shares Who is supposed to be watching: EBMT, CIBMTR, FACT-JACIE, and what a survivor is actually offered, Graft-versus-host disease (GVHD) and graft-versus-leukaemia, After a transplant or cell therapy: what to ask for, Allogeneic stem cell transplantation and the tags rejuvenation, survivorship, transplant.
Shares Who is supposed to be watching: EBMT, CIBMTR, FACT-JACIE, and what a survivor is actually offered, After a transplant or cell therapy: what to ask for, Allogeneic stem cell transplantation, Survivorship care and late-effects surveillance and the tags rejuvenation, survivorship, transplant.
Shares Who is supposed to be watching: EBMT, CIBMTR, FACT-JACIE, and what a survivor is actually offered, After a transplant or cell therapy: what to ask for, Autologous stem cell transplant (high-dose therapy), Allogeneic stem cell transplantation and the tags rejuvenation, survivorship, transplant.
Shares Graft-versus-host disease (GVHD) and graft-versus-leukaemia, After a transplant or cell therapy: what to ask for, Allogeneic stem cell transplantation, Survivorship care and late-effects surveillance and the tags rejuvenation, survivorship, transplant.