*Purpose: Less than 30% of pediatric liver transplant recipients are up-to-date on age-appropriate immunizations at the time of transplant despite being at high-risk for infections post-transplant. The aim of this study was to describe transplant-specific immunization barriers from the perspectives of all stakeholders.

*Methods: Semi-structured interviews were conducted with parents whose child received a liver transplant between January 2011 and December 2016, primary care providers, transplant nurse coordinators, infectious diseases physicians, transplant pharmacists and hepatologists at three geographically diverse large pediatric liver transplant centers in the United States. Interviews were conducted between July 2017 and August 2018. Aligned with grounded-theory methodology, the interview guide elicited participants’ thoughts and experiences regarding pre-transplant immunizations. Interviews were transcribed and inductively coded by a multi-disciplinary team. Coded transcripts were analyzed within and across participant groups to identify major themes.

*Results: Fifty stakeholders participated in 30-60 minute interviews. We identified five central themes regarding barriers to immunization of pediatric transplant patients: (1) inaccurate knowledge about pre-transplant immunizations (specifically regarding safety, efficacy, contraindications, and use of an accelerated immunization schedule), (2) lack of communication/coordination between team members regarding immunizations (identifying whose role it was to create the individualized immunization schedule versus whose role it was to administer the immunizations and ensure follow up) , (3) non-centralized location of immunization records (in state immunization registries, electronic medical records, parental records, primary care provider records, pharmacy records), (4) difficulty tracking when vaccines were next due and (5) immunizations not being a priority. Participants overwhelmingly believed that a health information technology tool could potentially address and overcome process gaps in the pre-transplant immunization process.

*Conclusions: This study reveals parental, provider and health system barriers to immunization of high-risk pediatric liver transplant candidates. Novel health information technology tools that address these barriers may help increase immunization rates in transplant candidates.

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