Immunocompromised Patients

Target population: adults and children with acute leukaemia, lymphoma, multiple myeloma, and patients with solid tumours who are scheduled to receive, are receiving, or have recently completed systemic anti-cancer therapy (chemotherapy, immunotherapy, targeted therapy, radiotherapy). The recommendations below apply to non-HSCT patients (HSCT-specific schedules are outside this table).

Timing of vaccination in general: ideally 2–4 weeks before chemotherapy; if this is not possible, give 3 months after chemotherapy when immune response improves. Patients who received anti-B-cell therapy (e.g., rituximab) have poor response—delay vaccination ≥6 months after rituximab for better response, when feasible.

Table 30.6 Recommended Immunisations for Adults with Cancer

Adapted from CDC Adult Immunization Schedule By Medical Condition and Other Indication.

Coadministration of two or more of the recommended non-live vaccines is acceptable per CDC guidelines. When given on separate days, there is no recommended waiting period.

Table 30.7 Recommendations for Other Vaccines That May Be Indicated for Adults with Cancer and Coexisting Health Conditions

Adapted from CDC. Adult Immunization Schedule by Medical Condition and Other Indication

Table 30.8 Timing Of Vaccination

Special Situations / Practical Points

Anti-B-cell therapies (e.g., rituximab, obinutuzumab): vaccines given during the period of B-cell depletion have poor immunogenicity. Defer non-urgent vaccination until ≥6 months (often 6–12 months) after completion of therapy when feasible; check serology before revaccination/boosting.
Timing relative to chemotherapy/immune recovery: when vaccinating during or after therapy, many authorities use ≥3 months after completion of cytotoxic chemotherapy as a pragmatic point for revaccination/primary vaccination, with longer intervals for intensive therapies or biologics. For planned immunosuppression, aim to vaccinate ≥2–4 weeks before
Household contacts and healthcare workers: should be current with routine vaccines (including annual IIV); live attenuated vaccines in contacts are usually allowed (except rare exceptions).
Serologic testing: consider post-vaccination serology for hepatitis B, chickenpox (when clinically relevant), and pneumococcus in select high-risk patients to confirm response and plan revaccination.
COVID-19 vaccination: immunocompromised cancer patients are a priority for COVID-19 vaccination and boosters per national guidance; multiple additional doses may be recommended (see specific COVID guidance).
High-risk conditions (asplenia, cGvHD, multiple myeloma, chronic lymphoid/ myeloid malignancy): favour conjugate pneumococcal vaccine and early revaccination schedules; consult ECIL/ASCO guidance.
Live vaccines are not given during chemotherapy and if patients remain immunosuppressed
Refer each disease’s section for a particular vaccine for further information on the individual vaccines (safety, efficacy, availability, etc.)

References

Kamboj, M., Bohlke, K., Baptiste, D. M., et al. (2024). Vaccination of Adults with Cancer: ASCO Guideline. Journal of Clinical Oncology: official Journal of the American Society of Clinical Oncology, 42(14), 1699–1721. https://doi.org/10.1200/JCO.24.00032
Mikulska, M., Cesaro, S., de Lavallade, H., et a European Conference on Infections in Leukaemia group (2019). Vaccination of patients with haematological malignancies who did not have transplantations: guidelines from the 2017 European Conference on Infections in Leukaemia (ECIL 7). The Lancet. Infectious diseases, 19(6), e188–e199. https://doi.org/10.1016/S1473-3099(18)30601-7
Rubin, L. G., Levin, M. J., Ljungman, P., et al. Infectious Diseases Society of America (2014). 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host. Clinical infectious Diseases : an official publication of the Infectious Diseases Society of America, 58(3), 309–318. https://doi.org/10.1093/cid/cit816
Centers for Disease Control and Prevention (CDC). General Best Practice Guidelines for Immunization: Altered Immunocompetence (Immunocompromised persons). CDC Vaccines & Immunizations. Updated online (2023–2024). Available from: https://www.cdc.gov/vaccines/hcp/imz-best-practices/altered-immunocompetence.html.
European Society for Medical Oncology (2023). ESMO Open and other oncology society guidance on vaccination of cancer patients (seasonal influenza, COVID-19 and pneumococcal vaccines) — see: “Vaccination for seasonal influenza, pneumococcal infection and herpes zoster in patients with cancer” (ESMO Open review) and society statements. ESMO Open. Available from: https://www.esmo.org.

Table 30.9 Vaccination after Haematopoietic Stem Cell Transplant (HSCT) (Allogeneic and Autologous)

^a DTPa for children less than 10 years of age; dTpa for those 10 years and above

^b If not specified, otherwise, the interval between doses is 1-2 month and the minimum interval between doses is 1 month

^c May be given as combined vaccines. Hexaxim (DTaP-IPV-HB-Hib) is a 6-in-1 combination vaccine

^dCheck titres 4–8 weeks after the last dose of post-transplant vaccine; if anti-HBs is <10 IU/mL, an additional 3 doses should be considered, but the benefit of this second series of vaccination is uncertain. A high dose formulation is preferred for these booster doses.

^eMeningococcal serogroups A, C, W, Y vaccine (MenACWY)

NOTES

Vaccination schedules are similar for allogeneic and autologous HCT recipients but grading of recommendations changes for some vaccines.
For autologous transplant recipients, many inactivated vaccines may be started 3 months post-autologous with primary series resumed as if vaccine-naïve in many programmes. Live attenuated vaccines should be deferred until ≥24 months after transplantation, and only when the patient is off immunosuppressive therapy and clinically recovered.
For some centres, influenza and COVID-19 can be started as early as 3 months post-transplant to allow seasonal protection, while pneumococcal/meningococcal/Hib vaccines are often initiated at 3–6 months
For CAR-T recipients, CDC recommends revaccination starting ≥3 months post-cellular therapy. (www2.cdc.gov, PMC)
General rule: Live attenuated vaccines (MMR, chickenpox) should not be given within the first 2 years after HSCT, or in patients with active GVHD or those receiving immunosuppressive therapy. Limited data are available regarding safety and efficacy.
Exceptional/conditional use: Some guidelines allow MMR and chickenpox vaccination ≥24 months post-HSCT in patients who have achieved immune recovery, have no GVHD and are off immunosuppressive therapy.
Inactivated vaccines can be given if the patient has cGVHD.
Inactivated Polio (IPV) and oral Polio vaccine (OPV) are not interchangeable.
In patients receiving prednisone ≥0.5 mg/kg bodyweight per day as part of a combination therapy or if a three-agent immunosuppressive treatment is given, vaccination may be postponed until immunosuppressive therapy is reduced to a double combination or prednisone < 0.5 mg/kg bodyweight daily in order to achieve a better vaccine response.
Following a complete revaccination program, regular assessment of seroprotection against diphtheria, poliomyelitis, tetanus, measles and HBV every 4–5 years is recommended in patients after HSCT.
Influenza and COVID-19 vaccines may be initiated as early as 3 months post-transplant during an outbreak.
Pneumococcal vaccine: There are two types of pneumococcal vaccine–conjugate vaccine (PCV13) and polysaccharide vaccine (PPSV23). PCV13 is used for the primary series because the immune response to conjugate vaccines is generally more immunogenic than polysaccharide vaccines; however, its spectrum of protection is narrower. Therefore, a subsequent dose of PPSV23 is given to broaden the immune response. PPSV23 protects against 23 strains but is less immunogenic and may elicit an inadequate response. It may be beneficial to use PPSV23 as the fourth dose to broaden the immune response. Adjunctive antibiotic prophylaxis may be given for patients with cGVHD.A multidose series is required due to loss of pre-transplant immunity. When PCV20 is used, administer a 3-dose series at intervals of at least 4 weeks. PPSV23 is not required when PCV20 is used.
For post-HSCT patients who wish to travel abroad, immunisation may be necessary. Patients should seek advice from their respective transplantation teams. Vaccines that should be safe for blood and marrow transplant patients intending to travel include:
- Typhoid: The oral form is contraindicated
- Cholera: Not recommended because of low protective efficacy
- Hepatitis A: Both active and passive are safe
  Live attenuated vaccines that are contraindicated include Yellow fever, Japanese encephalitis, and oral polio live vaccines
Hepatitis B virus (HBV)
Before allogeneic HSCT, patients who are negative for all HBV markers that are transplanted with a graft from an anti-HBc positive donor should be vaccinated if possible and could additionally receive anti-HBV immunoglobulins;
6 months after allogeneic and autologous HSCT, patients who were negative for HBV before transplantation and patients who were vaccinated before transplant but lost their immunity at 6 months should be vaccinated according to country recommendation (6–12 months after transplantation 3 doses should be administered,; patients infected with HBV before HSCT (HBsAg negative and anti-HBc positive) should be assessed regularly for anti-HBs antibody titres and should be vaccinated if they have unprotective titres; if anti-HBs titres are < 10 IU/, –8 weeks after the initial series of 3 vaccine doses, a second series of 3 doses should be considered For further details on individual vaccines (including safety, efficacy, and availability), please see the respective subsections.

The vaccination recommendations for close contacts of patients undergoing hematopoietic stem cell transplantation are as follows:

Review compliance with the national vaccination plan indicated for the age of family members.
Annual influenza and COVID-19 vaccine while the patient is considered immunocompromised.
Chickenpox and MMR vaccines for seronegative family members:
1. For those receiving the chickenpox vaccine, contact with the patient should be avoided for 6 weeks after vaccination.
2. For MMR, close contacts who have been recently vaccinated should avoid direct contact with the patient for 4 weeks after administration to minimise the risk of transmission.
If there are children in the household who have received the rotavirus vaccine, the patient should avoid contact with the child’s faeces (diaper handling; hygiene care) for 4 weeks after vaccination.

References

Australian Government Department of Health. (August 26, 2025). Table. Recommendations for vaccination after haematopoietic stem cell transplant in children and adults. In The Australian Immunisation Handbook. Retrieved October 30, 2025, from https://immunisationhandbook.health.gov.au/resources/tables/table-recommendations-for-vaccination-after-haematopoietic-stem-cell-transplant-in-children-and-adults
Cordonnier, C., Einarsdottir, S., Cesaro, S., et al. European Conference on Infections in Leukaemia group (2019). Vaccination of haemopoietic stem cell transplant recipients: Guidelines of the 2017 European Conference on Infections in Leukaemia (ECIL 7). The Lancet. Infectious Diseases, 19(6), e200–e212. https://doi.org/10.1016/S1473-3099(18)30600-5
Ullmann, A. J., Schmidt-Hieber, M., Bertz, H., et al. Infectious Diseases Working Party of the German Society for Hematology and Medical Oncology (AGIHO/DGHO) and the DAG-KBT (German Working Group for Blood and Marrow Transplantation) (2016). Infectious diseases in allogeneic haematopoietic stem cell transplantation: Prevention and Prophylaxis Strategy Guidelines 2016. Annals of Hematology, 95(9), 1435–1455. https://doi.org/10.1007/s00277-016-2711-1
Rieger, C. T., Liss, B., Mellinghoff, S., et al. German Society of Hematology and Medical Oncology Infectious Diseases Working Group (AGIHO) (2018). Anti-infective vaccination strategies in patients with hematologic malignancies or solid tumors-Guideline of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO). Annals of oncology: official journal of the European Society for Medical Oncology, 29(6), 1354–1365. https://doi.org/10.1093/annonc/mdy117
Ljungman, P., Cordonnier, C., Einsele, H., et al. Center for International Blood and Marrow Transplant Research, National Marrow Donor Program, European Blood and Marrow Transplant Group, American Society of Blood and Marrow Transplantation, Canadian Blood and Marrow Transplant Group, Infectious Disease Society of America, Society for Healthcare Epidemiology of America, Association of Medical Microbiology and Infectious Diseases Canada, & Centers for Disease Control and Prevention (2009). Vaccination of hematopoietic cell transplant recipients. Bone marrow transplantation, 44(8), 521–526. https://doi.org/10.1038/bmt.2009.263
de la Carrera, R. (2019). Vaccinations. p 208-219. In: Carreras, E., Dufour, C., Mohty, M., Kroger, N, (eds) the EBMT Handbook, Springer, Cham. http://doi.org/10.1007/978-3-030-02278-5_29.
Centers for Disease Control and Prevention (June 26, 2024). General Best Practice Guidelines for Immunization: Altered Immunocompetence. CDC Vaccines & Immunizations. Updated 2023–2024. Available from: https://www.cdc.gov/vaccines/hcp/imz-best-practices/altered-immunocompetence.html
European Society for Blood and Marrow Transplantation (EBMT) / EBMT Handbook (2024). Pavletic S, editor. Vaccinations. In: The EBMT Handbook. NCBI Bookshelf. Available from: https://www.ncbi.nlm.nih.gov/books/NBK608259/.
Silva-Pinto, A., Abareu, I., Martins, A., Bastos, J., Araujo, A and Pinto, R. (December 23, 2024). Vaccination After Haematopoietic Stem Cell Transplant: A Review of the Literature and Proposed Vaccination Protocol. Vaccines,12(12):1449. doi: 10.3390/vaccines12121449

Table 30.10 Recommendations for vaccination before and after solid organ transplant

These recommendations are based on the principle that, where possible, children and adults should complete an age-appropriate routine vaccination schedule before transplant. When needed, an accelerated or catch-up schedule may also be considered in the pre-transplant period. Immunogenicity is likely greater when vaccines are administered prior to transplant; if this has not been achieved, the transplant recipient should receive additional doses after transplant.

References

Australian Technical Advisory Group on Immunisation (ATAGI). Recommendations for vaccination before and after solid organ transplant in children and adults. In: The Australian Immunisation Handbook Updated 26 August 2025 https://immunisationhandbook.health.gov.au/resources/tables/table-recommendations-for-vaccination-before-and-after-solid-organ-transplant
Danziger-Isakov, L., Kumar, D. On Behalf of the AST ID Community of Practice (April 19, 2019). Vaccination of solid organ transplant candidates and recipients: Guidelines from the American society of transplantation infectious diseases community of practice. Clinical Transplantation, 33(9), e13563. https://doi.org/10.1111/ctr.13563