What vaccinations are recommended for a 23-year-old female with acute lymphoblastic leukemia (ALL) in remission, status post allogeneic hematopoietic stem cell transplant (HSCT), with graft-versus-host disease (GVHD) on ruxolitinib (Janus kinase inhibitor), according to Centers for Disease Control and Prevention (CDC) guidelines?

Vaccination Schedule for Post-Allogeneic HSCT Patient with GVHD on Ruxolitinib

The patient should follow a complete revaccination schedule starting at 6 months post-HSCT, with MenACWY vaccination specifically indicated at 6-12 months post-transplant according to CDC guidelines. 1

Vaccination Calendar for Post-HSCT Patient with GVHD

Timing Post-HSCT	Vaccines to Administer	Notes
6 months	• Inactivated influenza vaccine (seasonal)	Annual vaccination; avoid live attenuated influenza vaccine [1]
6-12 months	• PCV13 (pneumococcal conjugate) - 1st dose • Haemophilus influenzae type b (Hib) - 1st dose • Inactivated polio vaccine (IPV) - 1st dose • DTaP/Tdap - 1st dose • Hepatitis B - 1st dose • MenACWY (meningococcal conjugate) - 1st dose	MenACWY specifically indicated for ages 11-18 years [1]
8 months	• PCV13 - 2nd dose • Hib - 2nd dose • IPV - 2nd dose • DTaP/Tdap - 2nd dose • Hepatitis B - 2nd dose	Continue series [1]
10 months	• PCV13 - 3rd dose • Hib - 3rd dose • IPV - 3rd dose • DTaP/Tdap - 3rd dose • Hepatitis B - 3rd dose	Complete initial series [1]
12 months	• PPSV23 (pneumococcal polysaccharide)	If no chronic GVHD; for patients with chronic GVHD, give 4th dose of PCV13 instead [1]
24 months	• MMR (if seronegative and no active GVHD/immunosuppression) • Varicella (if seronegative and no active GVHD/immunosuppression)	Live vaccines contraindicated with active GVHD or ongoing immunosuppression [1]

Special Considerations for This Patient

1. GVHD and Ruxolitinib Impact:

   • The presence of GVHD and treatment with ruxolitinib (JAK inhibitor) significantly impacts vaccination timing and efficacy 1
   • Inactivated vaccines should still be administered starting at 6 months post-HSCT despite GVHD or immunosuppression 2
   • Live vaccines (MMR, varicella) are contraindicated while the patient has active GVHD or is on immunosuppression 1

2. MenACWY Vaccination:

   • MenACWY vaccination is specifically indicated for HSCT recipients aged 11-18 years, with two doses administered 6-12 months after HSCT 1
   • A booster dose should be given at age 16-18 years for those who received the initial post-HSCT dose at age 11-15 years 1

3. Pneumococcal Vaccination Strategy:

   • For patients with chronic GVHD, a fourth dose of PCV13 should be given at 12 months instead of PPSV23 1
   • If no chronic GVHD, give PPSV23 at 12 months after completing the PCV13 series 1

4. Hepatitis B Vaccination:

   • After completing the 3-dose series, check anti-HBs titers 1
   • If anti-HBs <10 mIU/mL, administer a second 3-dose series or consider high-dose formulation 1

Important Caveats

• HSCT recipients should be viewed as "never vaccinated" regardless of pre-transplant vaccination history 1, 2
• Antibody response may be suboptimal during the first year post-transplant, especially with GVHD and immunosuppression 2
• Vaccination of household contacts is crucial to create a protective cocoon around the patient 1
• Avoid live vaccines in close contacts if there is risk of transmission to the patient 1
• Annual influenza vaccination should be continued lifelong 1
• Serologic testing may be needed to confirm immunity after vaccination, particularly for hepatitis B 1

This vaccination schedule follows CDC guidelines for post-HSCT patients and addresses the specific needs of a patient with GVHD on immunosuppressive therapy. The schedule prioritizes protection against encapsulated organisms (pneumococcus, Hib, meningococcus) which pose particular risk to immunocompromised patients.