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Immunizations in adults with cancer

Immunizations in adults with cancer
Literature review current through: May 2024.
This topic last updated: Jan 22, 2024.

INTRODUCTION — Prevention of infection is of paramount importance to the ever-increasing population of patients who have impaired immunity. Infection in these patients often results in excessive morbidity and mortality, and antimicrobial therapy is often less effective than in the unimpaired host [1]. Although immunization appears to be an obvious way to prevent infection, many patients with impaired immunity are unable to mount a protective immune response to active vaccination. Furthermore, immunization with live-virus vaccines may result in unchecked proliferation of attenuated strains.

The risk of acquiring infection and the inability to prevent infection by immunization are directly related to the patient's "net state of immunosuppression" or severity of disease. The greater the degree of immunosuppression, the less likely the patient is to respond to immunization. Although certain existing vaccines provide some benefit to the immunocompromised patient, a vaccine response cannot be assumed. Successful protection of the immunocompromised adult may require the use of vaccines and/or passive immunization (ie, immune globulin) as well as adjunctive measures, such as antiviral drug prophylaxis during influenza A outbreaks. (See "Seasonal influenza in adults: Role of antiviral prophylaxis for prevention" and "Seasonal influenza in children: Management".)

The rationale for immunizing adults who have undergone chemotherapy for treatment of hematologic malignancies and solid tumors or who have other immunocompromising conditions will be reviewed here. Issues related to immunizations in patients who have had hematopoietic cell transplants or solid organ transplants or who are infected with human immunodeficiency virus (HIV) as well as in healthy children and adults are discussed separately. (See "Immunizations in hematopoietic cell transplant candidates, recipients, and donors" and "Immunizations in solid organ transplant candidates and recipients" and "Immunizations in persons with HIV" and "Standard immunizations for nonpregnant adults" and "Standard immunizations for children and adolescents: Overview".)

GENERAL APPROACH — Adults with cancer are at increased risk of serious infection, although the degree of risk varies based on underlying malignancy and type of immunosuppressive treatments used. Many of these infections are vaccine preventable. Patients with hematologic malignancies tend to be more immunocompromised than those with solid tumors. However, patients with solid tumors are also at risk of infection on the basis of debility, malnutrition, and, in some cases, anatomic obstruction (eg, lung masses obstructing bronchial drainage).

Vaccines are important for patients with cancer, but ideally should not be given during periods of immunosuppression from chemotherapy because, at such times, they may not be effective and live vaccines may result in vaccine-derived infections. The timing of immunizations in patients with cancer is discussed below. (See 'Timing of immunizations' below.)

Treatment for many cancers has intensified greatly in recent years, resulting in improved patient outcomes, but few studies of immunity and vaccination have been published during this time period. Immunization recommendations for immunocompromised patients in the United States have been developed by the Infectious Diseases Society of America (IDSA) [2]. The United States Advisory Committee on Immunization Practices (ACIP) also includes recommendations for immunocompromised patients in their guidelines (figure 1) [3]. Our recommendations are generally in keeping with those of the IDSA and the ACIP.

When both inactivated and live formulations of a given vaccine are available, the inactivated formulation is preferred in patients with cancer.

TIMING OF IMMUNIZATIONS — The timing of administration of immunizations in patients with cancer is summarized as follows [2,3]:

Immunizing prior to chemotherapy – All indicated vaccines should be given to adult cancer patients before initiation of chemotherapy, before therapy with other immunosuppressive drugs, and before radiation or splenectomy, when feasible (figure 1). Indicated inactivated vaccines should be given ≥2 weeks prior to chemotherapy, and indicated live-virus vaccines should be given ≥4 weeks prior to chemotherapy.

Avoidance of live vaccines during chemotherapy – Patients with cancer receiving chemotherapy or other immunosuppressive therapy should not receive live-virus vaccines because of the risk of vaccine-derived infections.

Inactivated immunizations during chemotherapy – Inactivated vaccines should generally be avoided in patients with cancer receiving chemotherapy or other immunosuppressive therapy because they may be less effective. However, we favor giving coronavirus disease 2019 (COVID-19) vaccines and an annual inactivated influenza vaccine to such patients given the need to protect against circulating strains of the viruses. Detailed recommendations about the timing of influenza vaccination administration are presented below. (See 'COVID-19 vaccine' below and 'Influenza vaccine' below.)

If other inactivated vaccines are given during chemotherapy, they should not be considered valid doses unless protective antibodies are documented. In such patients, vaccines should be readministered after the recovery of immune competence. Revaccination of individuals after chemotherapy or radiation is generally unnecessary if the prior vaccination occurred before chemotherapy, with the exception of hematopoietic cell transplant recipients. (See "Immunizations in hematopoietic cell transplant candidates, recipients, and donors".)

Immunizing following completion of chemotherapy – Patients with leukemia, lymphoma, or other malignancies whose disease is in remission, who haven't received anti-B cell antibodies (eg, rituximab, alemtuzumab), and whose chemotherapy has been terminated for at least three months may receive inactivated vaccines as well as live-virus vaccines such as the vaccines for measles, mumps, rubella, varicella, and the live attenuated zoster vaccine. In patients who have received anti-B cell antibodies (eg, rituximab, alemtuzumab) or other potently immunosuppressive treatments (eg, fludarabine), administration of inactivated and live vaccines should be delayed for at least six months.

Immunizing following hematopoietic cell transplant – Patients who have underwent a hematopoietic cell transplant should be revaccinated for most routine vaccines (table 1 and table 2). This is discussed in detail elsewhere. (See "Immunizations in hematopoietic cell transplant candidates, recipients, and donors", section on 'Timing and administration of vaccines'.)

INACTIVATED VACCINES

COVID-19 vaccine — Patients with cancer should be fully vaccinated against COVID-19. This is discussed in detail elsewhere. (See "COVID-19: Vaccines" and "COVID-19: Considerations in patients with cancer".)

Influenza vaccine — Adults with cancer should receive an inactivated influenza vaccine annually [2,4,5]. Although inactivated vaccines are generally avoided in patients receiving intensive chemotherapy (eg, induction or consolidation chemotherapy for acute leukemia), we favor giving an inactivated influenza vaccine to such patients given the need for annual administration to protect against circulating seasonal strains of influenza. Immunization of family members and hospital staff is also strongly recommended. The recommendations do not support administration of a second dose of the influenza vaccine within the same season [5].

As the immune response to the influenza vaccine is likely to be impaired in patients receiving chemotherapy, the vaccine is optimally administered at least two weeks before chemotherapy starts or following completion of chemotherapy if the patient is expected to finish chemotherapy early in the influenza season. If neither of these options is possible, we suggest immunizing patients about a week after the start of a chemotherapy cycle. This recommendation is based upon limited data from patients with solid tumors receiving chemotherapy, suggesting that immunization on day 4 or 5 of a chemotherapy cycle is more immunogenic than on day 16 [6,7]. There have been conflicting results regarding the immunogenicity of immunization on the first day of the chemotherapy cycle, with one study showing poor immunogenicity [8] but another study showing good immunogenicity [9]. Annual immunization of all family members and other close contacts is also recommended. (See "Seasonal influenza vaccination in adults" and "Seasonal influenza in children: Prevention with vaccines" and "Infection control measures for prevention of seasonal influenza".)

Patients with acute leukemia undergoing induction chemotherapy are at greatest risk of morbidity and mortality associated with influenza [10]. Most infections in such patients are acquired nosocomially [10]. Reported seroconversion rates to the inactivated influenza vaccine in patients with cancer have ranged between 24 and 78 percent [11-13]; a two-dose regimen does not appear to improve the response [14,15]. In a 2012 meta-analysis, seroconversion and seroprotection rates following influenza vaccination in patients with cancer were approximately one-third of those observed in immunocompetent patients [16]. The likelihood of response is affected by the intensity and type of chemotherapy and the timing of vaccine administration in the chemotherapy cycle.

Patients receiving anti-CD20 monoclonal antibodies (eg, rituximab, alemtuzumab) have an attenuated immune response to vaccines. In a study of lymphoma patients who received a rituximab-containing treatment regimen within the previous six months, none of the 67 patients developed seroprotective titers following administration of an adjuvanted inactivated pandemic H1N1 influenza A vaccine compared with 42 of the 51 (82 percent) healthy controls [17].

Intranasally administered live attenuated influenza vaccine (LAIV) is not recommended in immunocompromised individuals. LAIV is considered safe for healthy nonpregnant individuals between 2 and 49 years of age [2,5]. Either the inactivated influenza vaccine or LAIV can be used in household contacts and health care workers caring for patients with cancer; However, only the inactivated influenza vaccine should be used among contacts of hematopoietic cell transplant (HCT) recipients within two months of transplant and of HCT recipients with graft-versus-host disease [5]. (See "Seasonal influenza vaccination in adults", section on 'Choice of vaccine formulation' and "Immunizations for health care providers", section on 'Recommendation' and "Seasonal influenza vaccination in adults" and "Immunizations in hematopoietic cell transplant candidates, recipients, and donors", section on 'Household contacts'.)

Antiviral prophylaxis should be considered for those undergoing the most intense chemotherapy under certain circumstances, such as within the first 48 hours following an exposure in an unvaccinated individual or when there is a poor match between the vaccine and circulating viruses. Detailed recommendations regarding antiviral prophylaxis are presented separately. (See "Seasonal influenza in adults: Role of antiviral prophylaxis for prevention", section on 'Postexposure antiviral prophylaxis' and "Seasonal influenza in children: Prevention with antiviral drugs", section on 'Outpatient settings'.)

Pneumococcal vaccine — All patients with cancer should be vaccinated against Streptococcus pneumoniae (pneumococcus) [18]. Pneumococcal infections are an important cause of morbidity and mortality in oncology patients and vaccination has been shown to reduce morbidity [19,20].

Our approach to vaccination is concordant with the United States Advisory Committee on Immunization Practices [18]:

Patients who have not previously been vaccinated should receive either the 20-valent pneumococcal conjugate vaccine (PCV20) alone or the 15-valent pneumococcal conjugate vaccine (PCV15) followed by the pneumococcal polysaccharide vaccine-23 (PPSV23) at least eight weeks later.

For patients who have already received a previously recommended pneumococcal conjugate vaccine (eg, the 13-valent pneumococcal conjugate vaccine [PCV13], the 10-valent pneumococcal conjugate vaccine [PCV10]) or PPSV23, the dosing schedule varies (table 3 and table 4).

To optimize the immune response to vaccination, we vaccinate oncology patients prior to receipt of chemotherapy, when possible. We also avoid vaccination during intense cycles of chemotherapy and during other periods of intense immunosuppression. (See 'Timing of immunizations' above.)

PCV15 and PCV20 are pneumococcal conjugate vaccines that protect against additional pneumococcal serotypes compared with PCV13. PCV20 alone and PCV15 in combination with PPSV23 have both been shown to be immunogenic and safe in immunocompetent patients [21,22]. However, there are no studies that have compared vaccine effectiveness of PCV20 alone or PCV15 combined with PPSV23 to PCV13 combined with PPSV23 in cancer patients.

Pneumococcal conjugate vaccines that contain a different number of serotypes (eg, PCV10) are used in some countries in Europe and elsewhere. When PCV15 or PCV20 are not available, patients should be vaccinated against pneumococcus according to their national guidelines.

Most of the data on pneumococcal vaccination in patients with cancer are with PPSV23 or with PPSV23 in combination with PCV. Responses to PPSV23 vary but are better (even close to normal) if the vaccine is administered prior to the onset of therapy [23-27]. Response to PPSV23 is greatly diminished after chemotherapy. Vaccine responses are particularly poor after initiating cancer treatment in patients with leukemia [28] and head and neck cancers [27]. Among patients with Hodgkin lymphoma, for example, vaccine responses remain impaired for as long as seven years after treatment [24]. At least in Hodgkin lymphoma, priming with the seven-valent pneumococcal conjugate vaccine (PCV7; Prevnar 7) appears to improve the response to the subsequent administration of PPSV23 [29]. It is likely that administration of other pneumococcal conjugate vaccines (eg, PCV13, PCV15, PCV20) have the same effect on subsequent PPSV23 administration as PCV7.

The approach to pneumococcal vaccination varies among experts and clinical practice guidelines. Specifically, some experts favor revaccination with PPSV23 as the immune response to PPSV23 wanes over time. This is discussed in detail separately. (See "Pneumococcal vaccination in adults".)

Tetanus toxoid, diphtheria toxoid, and pertussis vaccines — Many oncology patients receiving chemotherapy are not protected against tetanus, diphtheria, and pertussis. In one report, for example, only 59 percent of patients being treated for acute leukemia were protected against tetanus [30]. Little is known about response to tetanus and diphtheria immunization in the heterogeneous population of cancer patients, although, in one study, children on maintenance chemotherapy had an immune response similar to that observed in healthy children [31].

Tetanus and diphtheria booster immunizations should be considered for all patients with cancer who are due for vaccination. In addition, adults who have not been vaccinated with the acellular pertussis vaccine should receive the vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap). Tetanus and diphtheria toxoid (Td) or Tdap should ideally be given before starting treatment and preferably not during cycles of intensive chemotherapy. Pertussis vaccination in children is discussed separately. (See "Tetanus-diphtheria toxoid vaccination in adults" and "Pertussis infection in adolescents and adults: Treatment and prevention" and "Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age" and "Diphtheria, tetanus, and pertussis immunization in children 6 weeks through 6 years of age", section on 'Schedules'.)

Hepatitis B vaccine — All unvaccinated patients with cancer aged 19 to 59 years and those ≥60 years old with risk factors (eg, diabetes mellitus, chronic liver disease, hepatitis C, hemodialysis, and other risk factors) should receive the hepatitis B vaccine [32]. As with other vaccines, cancer patients may have suboptimal response to the hepatitis B vaccine. Regimens that include doubling the standard antigen dose or administering additional doses may increase response rates but, given the limited data with these alternative regimens, this approach cannot be routinely recommended. Hepatitis B and hepatitis A vaccines may be coadministered to cancer patients. (See "Hepatitis B virus immunization in adults".)

Hepatitis A vaccine — Cancer patients who have any risk factors for developing hepatitis A should receive the hepatitis A vaccine. As above, vaccine efficacy may be compromised in cancer patients. (See "Hepatitis A virus infection: Treatment and prevention".)

Human papillomavirus vaccine — Cancer patients through age 26 (and some adults aged 27 to 45 years) with an indication for human papillomavirus (HPV) vaccination should be immunized [33]. However, cancer patients may have a suboptimal antibody response and lower vaccine efficacy. Patients with thrombocytopenia are at risk of developing a hematoma after the intramuscular injection of the vaccine. Indications for HPV vaccination are discussed separately. (See "Human papillomavirus vaccination".)

Meningococcal vaccine — Meningococcal vaccination is recommended for individuals at increased risk for meningococcal infection, such as children between 11 and 18 years of age and certain other groups (college freshmen living in dormitories, individuals traveling to countries where Neisseria meningitidis is hyperendemic or epidemic, patients undergoing treatment with eculizumab or with terminal complement component deficiencies or anatomic or functional asplenia, and others).

There are no specific recommendations for patients with cancer, but any adult cancer patient who has another indication for meningococcal vaccination should be vaccinated [34]. Vaccine response may be suboptimal in cancer patients [2,3]. The appropriate formulation and vaccine schedule depends upon the individual's age and underlying illness. This is discussed in detail separately. (See "Meningococcal vaccination in children and adults", section on 'Indications and schedules in the United States'.)

Haemophilus influenzae vaccine — Adult cancer patients are not at significant risk of developing Haemophilus influenzae type b (Hib) disease. Hib immunization is therefore not routinely recommended for adult cancer patients unless they undergo HCT or if they have had a splenectomy (figure 1). (See "Immunizations in hematopoietic cell transplant candidates, recipients, and donors", section on 'Haemophilus influenzae' and "Prevention of Haemophilus influenzae type b infection", section on 'High risk of invasive Hib disease'.)

Polio vaccine — The inactivated polio vaccine is the only poliovirus vaccine recommended for immunodeficient individuals and their household contacts [35]. However, a protective immune response cannot be assured in patients who are immunodeficient at the time of vaccination. (See "Poliovirus vaccination".)

Respiratory syncytial virus (RSV) — Patients with cancer are at increased risk for RSV disease. In accordance with the ACIP, we use shared clinical decision making and discuss the benefits and the potential risks of the RSV vaccine with all patients with cancer who are 60 years or older to help them decide on their need for the vaccine (table 5) [32]. Risk for hospitalization and death from RSV will vary among the population with cancer, depending on age, type and extent of the cancer, other comorbidities, and the type and timing of chemotherapy. Although the trials excluded patients with malignancy, we believe the benefits generally outweigh the potential risks.

ZOSTER VACCINE — There are two vaccine formulations available for the prevention of herpes zoster: the recombinant (nonlive) zoster vaccine (RZV) and the live attenuated zoster vaccine (ZVL); ZVL is no longer available in the United States. For all patients, we prefer the two-dose RZV series over a single dose of the ZVL vaccine given better efficacy and safety of RZV. Detailed information and a description of the differences between the two vaccines is discussed elsewhere. (See "Vaccination for the prevention of shingles (herpes zoster)".)

We agree with recommendations from the United States Advisory Committee on Immunization Practices to vaccinate immunocompromised individuals ≥19 years of age, such as patients with cancer, against herpes zoster with the RZV [36]. Prior to vaccination, we confirm prior exposure to varicella in all immunocompromised individuals.

RZV as preferred option − RZV is administered in two doses spaced two to six months apart [36]. However, in patients who are or will be immunosuppressed and would benefit from receiving the full vaccination series earlier, the second dose can be given as early as four weeks after the first dose. Timing of vaccine administration relative to cancer treatment is discussed above (see 'Timing of immunizations' above). For patients who have received ZVL prior to oncologic diagnosis and treatment, we suggest revaccination with RZV. Since these patients have some immunity against herpes zoster from their previous vaccination, it may be reasonable to delay revaccination with RZV in patients undergoing chemotherapy until completion of treatment to optimize immunogenic response to the vaccine.

Patients with hematologic malignancies and solid tumors are at increased risk of developing herpes zoster (shingles) [37]. The incidence varies by type of cancer and treatment. Patients with Hodgkin disease are at particularly high risk for developing zoster, with rates approaching 30 percent during illness or its treatment [38].

Vaccination with RZV has been shown to be effective in eliciting humoral and cell-mediated immune responses against herpes zoster in patients with solid and hematologic cancers. In a randomized trial of 262 patients ≥18 years of age with solid tumors who received RZV (given as two doses one to two months apart) or placebo either before or during chemotherapy, RZV was safe and immunogenic; both humoral and cell-mediated immune responses persisted one year after vaccination [39]. Although all patients receiving RZV developed humoral immune response, those who received the vaccine prior to initiation of chemotherapy had higher immune responses compared with those who received the vaccine during chemotherapy. In a randomized trial of 569 patients ≥18 years of age with hematologic malignancies who received RZV (given as two doses one to two months apart) versus placebo, 80.4 percent of the vaccinated group developed a humoral immune response to herpes zoster compared with 0.8 percent in the unvaccinated group [40]. The immune response persisted through 13 months of follow up. Two patients in the vaccinated group developed herpes zoster compared with 12 in the unvaccinated group. No difference in adverse events was detected between the two groups.

ZVL as less preferred alternative – In settings where RZV is not available, ZVL is an alternative option for vaccination against herpes zoster. ZVL is administered as a single dose and should be given at least four weeks prior to the onset of immunosuppression. ZVL is contraindicated in those who are receiving moderate- to high-dose immunosuppressive therapy, such as cancer chemotherapy.

In locations where RZV is unavailable, patients with cancer who were previously vaccinated with ZVL will likely maintain some protection against herpes zoster. In a cohort study of individuals ≥60 years of age receiving myelosuppressive chemotherapy for solid tumors (4710 of whom had previously received ZVL and 16,766 of whom had not), the adjusted hazard ratio for herpes zoster among previously vaccinated individuals was 0.58 (95% CI 0.46-0.73) [41]. No vaccinated and six unvaccinated patients were hospitalized for herpes zoster.

However, as above, ZVL should not be administered to immunocompromised patients. The risk of ZVL in patients who have received immunosuppressive chemotherapy was illustrated by a fatal case of vaccine-derived disseminated varicella zoster infection reported in a 79-year-old man with chronic lymphocytic leukemia [42]. He had received ZVL six months after completing six cycles of fludarabine, cyclophosphamide, and rituximab; his remission status was not reported. The long-lasting immune effects of fludarabine and rituximab therapy as well as his advanced age may have predisposed this patient to disseminated infection.

LIVE-VIRUS VACCINES — Patients with cancer receiving chemotherapy should not receive live-virus vaccines (table 6) [2]. Recommendations regarding the timing of administration of live vaccines are discussed above. (See 'Timing of immunizations' above.)

Measles, mumps, and rubella vaccines — Cancer patients who are infected with measles have a high mortality rate [43]. Patients without immunity to measles, mumps, or rubella should be immunized prior to the initiation of immunosuppressive therapy. Recommendations regarding the timing of administration of live vaccines are discussed above. (See 'Timing of immunizations' above.)

Further information on the measles, mumps, and rubella vaccine is found elsewhere. (See "Measles, mumps, and rubella immunization in adults".)

The United States Advisory Committee on Immunization Practices recommendations state that severely immunocompromised patients who have been exposed to measles should receive 400 mg/kg of intravenous immune globulin, regardless of vaccination or immunologic status [44]. Severely immunocompromised cancer patients include those receiving treatment for acute lymphoblastic leukemia until at least six months after completing therapy. (See "Measles, mumps, and rubella immunization in adults", section on 'Post-exposure prophylaxis'.)

Varicella vaccine — Primary varicella is associated with high rates of morbidity and mortality in seronegative adults with cancer. Varicella vaccine should be administered to individuals without immunity to varicella prior to initiation of immunosuppressive therapy. Recommendations regarding the timing of administration of live vaccines are discussed above. (See 'Timing of immunizations' above.)

Further information on varicella vaccine is found elsewhere. (See "Vaccination for the prevention of chickenpox (primary varicella infection)".)

The varicella vaccine may be administered to susceptible household and other close contacts of cancer patients because transmission of varicella vaccine is rare [2,3]. If the household contact develops a rash after vaccination, the household contact should avoid direct contact with the immunocompromised cancer patient [45]. (See "Vaccination for the prevention of chickenpox (primary varicella infection)", section on 'Contacts of immunocompromised hosts'.)

One study evaluated the efficacy of the varicella vaccine in children in remission after treatment for leukemia [46]. The seroconversion rate was 88 and 98 percent after the first and second dose, respectively. There were few side effects, and breakthrough vaccine disease was effectively treated with acyclovir. Based upon this study, it is reasonable to immunize susceptible adult oncology patients with the varicella vaccine after completion of chemotherapy.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Immunizations in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Beyond the Basics topic (see "Patient education: Vaccines for adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Background − Prevention of infection is of paramount importance to the ever-increasing population of patients who have impaired immunity. Infection in these patients often results in excessive morbidity and mortality, and antimicrobial therapy is often less effective than in the unimpaired host. Although immunization appears to be an obvious way to prevent infection, many patients with impaired immunity are unable to mount a protective immune response to active vaccination. (See 'Introduction' above.)

ACIP vaccination schedule − The United States Advisory Committee on Immunization Practices (ACIP) immunization schedule for adults with medical conditions is presented in the following figure (figure 1). (See 'General approach' above.)

Timing of immunizations

All vaccines − All indicated vaccines should be given to adult cancer patients before initiation of chemotherapy, before therapy with other immunosuppressive drugs, and before radiation or splenectomy, when feasible.

Patients with cancer receiving chemotherapy or other immunosuppressive therapy should not receive live vaccines and should generally not receive inactivated vaccines. Live vaccines carry the risk of infection, and immunogenicity of inactivated vaccines is attenuated during cancer treatment.

Inactivated vaccines − Inactivated vaccines should be given ≥2 weeks prior to chemotherapy. However, we favor giving an inactivated influenza vaccine, even if the patient is receiving chemotherapy or other immunosuppressive therapy, given the need for annual seasonal administration to protect against influenza. (See 'Timing of immunizations' above and 'Inactivated vaccines' above.)

Live vaccines − Live-virus vaccines should be given ≥4 weeks prior to chemotherapy. Patients with leukemia, lymphoma, or other malignancies whose disease is in remission, who have not received anti-B cell antibodies (eg, rituximab, alemtuzumab), and whose chemotherapy was completed at least three months previously may receive live-virus vaccines, such as the vaccines for measles, mumps, rubella, and varicella. In patients who have received anti-B cell antibodies, administration of inactivated and live vaccines should be delayed for at least six months. (See 'Timing of immunizations' above and 'Live-virus vaccines' above.)

  1. Hibberd PL, Rubin RH. Approach to immunization in the immunosuppressed host. Infect Dis Clin North Am 1990; 4:123.
  2. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.
  3. Kroger A, Bahta L, Hunter P. General Best Practice Guidelines for Immunization. Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html (Accessed on January 24, 2022).
  4. Taplitz RA, Kennedy EB, Bow EJ, et al. Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: ASCO and IDSA Clinical Practice Guideline Update. J Clin Oncol 2018; 36:3043.
  5. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2023–24 Influenza Season. Morbidity and Mortality Weekly Report (MMWR), Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/72/rr/rr7202a1.htm (Accessed on October 05, 2023).
  6. Meerveld-Eggink A, de Weerdt O, van der Velden AMT, et al. Response to influenza virus vaccination during chemotherapy in patients with breast cancer. Ann Oncol 2011; 22:2031.
  7. Wumkes ML, van der Velden AM, Los M, et al. Serum antibody response to influenza virus vaccination during chemotherapy treatment in adult patients with solid tumours. Vaccine 2013; 31:6177.
  8. Ortbals DW, Liebhaber H, Presant CA, et al. Influenza immunization of adult patients with malignant diseases. Ann Intern Med 1977; 87:552.
  9. Keam B, Kim MK, Choi Y, et al. Optimal timing of influenza vaccination during 3-week cytotoxic chemotherapy cycles. Cancer 2017; 123:841.
  10. Elting LS, Whimbey E, Lo W, et al. Epidemiology of influenza A virus infection in patients with acute or chronic leukemia. Support Care Cancer 1995; 3:198.
  11. Gribabis DA, Panayiotidis P, Boussiotis VA, et al. Influenza virus vaccine in B-cell chronic lymphocytic leukaemia patients. Acta Haematol 1994; 91:115.
  12. Anderson H, Petrie K, Berrisford C, et al. Seroconversion after influenza vaccination in patients with lung cancer. Br J Cancer 1999; 80:219.
  13. Brydak LB, Całbecka M. Immunogenicity of influenza vaccine in patients with hemato-oncological disorders. Leuk Lymphoma 1999; 32:369.
  14. Lo W, Whimbey E, Elting L, et al. Antibody response to a two-dose influenza vaccine regimen in adult lymphoma patients on chemotherapy. Eur J Clin Microbiol Infect Dis 1993; 12:778.
  15. Ljungman P, Nahi H, Linde A. Vaccination of patients with haematological malignancies with one or two doses of influenza vaccine: a randomised study. Br J Haematol 2005; 130:96.
  16. Beck CR, McKenzie BC, Hashim AB, et al. Influenza vaccination for immunocompromised patients: systematic review and meta-analysis by etiology. J Infect Dis 2012; 206:1250.
  17. Yri OE, Torfoss D, Hungnes O, et al. Rituximab blocks protective serologic response to influenza A (H1N1) 2009 vaccination in lymphoma patients during or within 6 months after treatment. Blood 2011; 118:6769.
  18. Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:109.
  19. Andersen MA, Niemann CU, Rostgaard K, et al. Differences and Temporal Changes in Risk of Invasive Pneumococcal Disease in Adults with Hematological Malignancies: Results from a Nationwide 16-Year Cohort Study. Clin Infect Dis 2021; 72:463.
  20. Chiou WY, Lee MS, Hung SK, et al. Effectiveness of 23-valent pneumococcal polysaccharide vaccine on elderly long-term cancer survivors: a population-based propensity score matched cohort study. BMJ Open 2018; 8:e019364.
  21. A Study to Evaluate the Safety, Tolerability, and Immunogenicity of V114 Followed by PNEUMOVAX™23 in Adults at Increased Risk for Pneumococcal Disease (V114-017/PNEU-DAY). https://clinicaltrials.gov/ct2/show/record/NCT03547167 (Accessed on December 15, 2021).
  22. Klein NP, Peyrani P, Yacisin K, et al. A phase 3, randomized, double-blind study to evaluate the immunogenicity and safety of 3 lots of 20-valent pneumococcal conjugate vaccine in pneumococcal vaccine-naive adults 18 through 49 years of age. Vaccine 2021; 39:5428.
  23. Addiego JE Jr, Ammann AJ, Schiffman G, et al. Response to pneumococcal polysaccharide vaccine in patients with untreated Hodgkin's disease. Children's Cancer Study Group Report. Lancet 1980; 2:450.
  24. Frederiksen B, Specht L, Henrichsen J, et al. Antibody response to pneumococcal vaccine in patients with early stage Hodgkin's disease. Eur J Haematol 1989; 43:45.
  25. Donaldson SS, Vosti KL, Berberich FR, et al. Response to pneumococcal vaccine among children with Hodgkin's disease. Rev Infect Dis 1981; 3 Suppl:S133.
  26. Siber GR, Gorham C, Martin P, et al. Antibody response to pretreatment immunization and post-treatment boosting with bacterial polysaccharide vaccines in patients with Hodgkin's disease. Ann Intern Med 1986; 104:467.
  27. Ammann AJ, Schiffman G, Addiego JE, et al. Immunization of immunosuppressed patients with pneumococcal polysaccharide vaccine. Rev Infect Dis 1981; 3 Suppl:S160.
  28. Feldman S, Malone W, Wilbur R, Schiffman G. Pneumococcal vaccination in children with acute lymphocytic leukemia. Med Pediatr Oncol 1985; 13:69.
  29. Chan CY, Molrine DC, George S, et al. Pneumococcal conjugate vaccine primes for antibody responses to polysaccharide pneumococcal vaccine after treatment of Hodgkin's disease. J Infect Dis 1996; 173:256.
  30. Hamarström V, Pauksen K, Svensson H, et al. Tetanus immunity in patients with hematological malignancies. Support Care Cancer 1998; 6:469.
  31. Prevots DR, Burr RK, Sutter RW, et al. Poliomyelitis prevention in the United States. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2000; 49:1.
  32. Murthy N, Wodi AP, McNally VV, et al. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2024. MMWR Morb Mortal Wkly Rep 2024; 73:11.
  33. Meites E, Szilagyi PG, Chesson HW, et al. Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2019; 68:698.
  34. Mbaeyi SA, Bozio CH, Duffy J, et al. Meningococcal Vaccination: Recommendations of the Advisory Committee on Immunization Practices, United States, 2020. MMWR Recomm Rep 2020; 69:1.
  35. Task Force on Community Preventive Services. Strategies for reducing exposure to environmental tobacco smoke, increasing tobacco-use cessation, and reducing initiation in communities and health-care systems. A report on recommendations of the Task Force on Community Preventive Services. MMWR Recomm Rep 2000; 49:1.
  36. Anderson TC, Masters NB, Guo A, et al. Use of Recombinant Zoster Vaccine in Immunocompromised Adults Aged ≥19 Years: Recommendations of the Advisory Committee on Immunization Practices - United States, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:80.
  37. McKay SL, Guo A, Pergam SA, Dooling K. Herpes Zoster Risk in Immunocompromised Adults in the United States: A Systematic Review. Clin Infect Dis 2020; 71:e125.
  38. Wilson JF, Marsa GW, Johnson RE. Herpes zoster in Hodgkin's disease. Clinical, histologic, and immunologic correlations. Cancer 1972; 29:461.
  39. Vink P, Delgado Mingorance I, Maximiano Alonso C, et al. Immunogenicity and safety of the adjuvanted recombinant zoster vaccine in patients with solid tumors, vaccinated before or during chemotherapy: A randomized trial. Cancer 2019; 125:1301.
  40. Dagnew AF, Ilhan O, Lee WS, et al. Immunogenicity and safety of the adjuvanted recombinant zoster vaccine in adults with haematological malignancies: a phase 3, randomised, clinical trial and post-hoc efficacy analysis. Lancet Infect Dis 2019; 19:988.
  41. Tseng HF, Tartof S, Harpaz R, et al. Vaccination against zoster remains effective in older adults who later undergo chemotherapy. Clin Infect Dis 2014; 59:913.
  42. Costa E, Buxton J, Brown J, et al. Fatal disseminated varicella zoster infection following zoster vaccination in an immunocompromised patient. BMJ Case Rep 2016; 2016.
  43. Kaplan LJ, Daum RS, Smaron M, McCarthy CA. Severe measles in immunocompromised patients. JAMA 1992; 267:1237.
  44. McLean HQ, Fiebelkorn AP, Temte JL, et al. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62:1.
  45. Grossberg R, Harpaz R, Rubtcova E, et al. Secondary transmission of varicella vaccine virus in a chronic care facility for children. J Pediatr 2006; 148:842.
  46. Gershon AA, Steinberg SP. Persistence of immunity to varicella in children with leukemia immunized with live attenuated varicella vaccine. N Engl J Med 1989; 320:892.
Topic 3899 Version 52.0

References

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