This article is more than 5 years old. Information may no longer be current.
Selection, timing of vaccines for patients with cancer require careful consideration
Questions about which vaccinations are safe to administer to patients with cancer — and the ideal time to administer them to patients on active cancer therapy — frequently arise in the clinic.
The CDC's Advisory Committee on Immunization Practices develops and periodically reviews the adult immunization schedule followed in clinical practice. The ACIP has recommendations regarding immunocompromised individuals, but not specifically those with cancer.
Although data supporting most vaccination recommendations in cancer patients are scant, providers now have some additional guidance in this area.
The Infectious Diseases Society of America recently published a clinical practice guideline for vaccination of the immunocompromised host, including patients with cancer. Although the IDSA guideline addresses pediatric patients with cancer and those who have undergone hematopoietic stem cell transplantation, this column will focus on adults with cancer.
Patients at risk
Who should be considered immunocompromised for the purpose of vaccine administration?
Patients with hematologic malignancies are immunocompromised due to frequent and/or long periods of neutropenia, T-cell dysfunction/depletion, use of corticosteroids, etc. Several studies have documented the lack of response to vaccination in patients receiving rituximab (Rituxan; Genentech, Biogen Idec) therapy. Additionally, patients with multiple myeloma have impaired ability to mount sufficient response to vaccination. A recent publication describes how tyrosine kinase inhibitors that are used to treat chronic myeloid leukemia decrease humoral immunity and the response to pneumococcal vaccination. In recognition of the varying intensity of cancer therapies and the emerging data with targeted therapies, the IDSA guideline considers all patients receiving cancer chemotherapy as having a high level of immunosuppression. Providers will need to make individualized assessments of the degree of immunosuppression experienced by each patient.
Debbie Blamble
For those patients deemed unable to receive vaccinations, other precautions should be taken to prevent active infections, such as ensuring that health care workers, caregivers, household contacts and family members are vaccinated. Additionally, patients may need to wear a mask and avoid crowds during times of elevated risk (eg, influenza season).
Recommended vaccinations
All adults should receive the annual influenza vaccine. There are two available influenza vaccine products: the trivalent inactivated influenza vaccine and the live-attenuated influenza vaccine. LAIV, an intranasal product, should not be administered to immunocompromised patients.
Some patients are unlikely to mount a sufficient response to the TIV. They include patients on intensive chemotherapy (eg, acute leukemia induction and consolidation) and those who have received monoclonal antibodies against B cells (eg, rituximab) in the previous 6 months. Among those patient populations, the IDSA guideline does not recommend vaccination.
The pneumococcal vaccine also is routinely recommended for adults. Two types are used — the 13-valent pneumococcal conjugate vaccine (PCV13; Prevnar 13, Pfizer) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23, Merck).
PSV13 is the primary pneumococcal vaccine administered during childhood, and PPSV23 is primarily used to prevent pneumococcal infections in adults. Per the ACIP guideline, at a minimum, all adults older than 65 years who received PPSV23 more than 5 years earlier — and were younger than 65 years at the time — should receive a one-time revaccination with PPSV23.
There are additional recommendations for immunocompromised adults. The IDSA guideline recommends that patients newly diagnosed with cancer — both solid tumors and hematologic malignancies — who have not previously received PCV13 should receive it, followed 8 weeks later by PPSV23. Most adults have not previously received PCV13, as it was just included as a routine childhood vaccination in 2010.
For those adults who previously received PPSV23, PCV13 should be given at least 1 year after the most recent PPSV23 dose. For those aged 19 to 64 years, a second PPSV23 dose should be administered 5 years after the first dose. An additional PPSV23 dose will be administered once the patient is older than 65 years and at least 5 years have elapsed from the previous vaccination.
Contraindicated vaccinations
Several vaccines contain live virus or bacteria. Administration of those vaccines would be contraindicated in an immunocompromised host due to potential development of a clinical infection from the live organism.
The intranasal influenza vaccine contains live-attenuated virus and, therefore, should not be administered to immunocompromised patients. For those patients in need of vaccination against influenza, TIV should be used.
The zoster vaccine, recommended for older adults, also contains live virus. Therefore, immunocompromised older adults should postpone receiving the zoster vaccine until no longer considered immunocompromised. Household members of immunocompromised patients may receive the zoster vaccine. However, if the household member develops any skin lesions after vaccination, the patient should avoid close contact with the household member until the skin lesions have resolved.
The oral polio vaccine, no longer available in the United States but still used elsewhere in the world, contains live virus. The vaccine can cause paralytic disease in immunocompromised patients. Therefore, administration would be contraindicated for both the patient and any household contacts.
Other vaccines that contain live virus and may be indicated in certain adults include the varicella vaccine and the measles, mumps, rubella vaccine. The yellow fever vaccine, recommended in certain international travel situations, contains live virus. There are two live bacteria vaccines that are not part of the recommended adult immunization schedule: the bacillus Calmette-Guérin (BCG) vaccine and the oral, live-attenuated typhoid vaccine. If needed, all of these vaccines should be postponed until the patient is no longer considered immunocompromised.
The IDSA guideline also recommends highly immunocompromised patients should avoid for 4 weeks changing the diapers of infants who have received the rotavirus vaccine, a live virus vaccine.
Vaccination timing
The IDSA guideline recommends live vaccines be administered at least 4 weeks before immunosuppression to allow time for an immune response to be mounted and the live virus to be cleared.
Inactivated vaccines should be administered at least 2 weeks before immunosuppression. Administering inactivated vaccines during chemotherapy may result in a reduced immune response. If administration of a vaccine is necessary, limited data suggest scheduling the vaccination between cycles, not on the first day of a cycle. Response to a vaccination may be suboptimal, so certain vaccines may need to be repeated when the patient is no longer considered immunocompromised.
Most patients with cancer can resume a routine vaccination schedule including both live and inactivated vaccines at least 3 months after the last cycle of chemotherapy. Patients who received treatment that included monoclonal antibodies against B cells should delay resuming the routine vaccination schedule until at least 6 months after the last cycle of cancer treatment. Data have shown that patients who receive inactivated vaccines within 6 months of rituximab therapy are unable to achieve protective titers.
Conclusion
The new IDSA guideline on vaccination of the immunocompromised host includes recommendations for patients with cancer. The guideline highlights the need to carefully consider which vaccines should be administered to patients with cancer, as well as the preferred timing of administration.
Generally recommended vaccines include the inactivated influenza vaccine, as well as pneumococcal vaccination. Live virus or bacteria vaccines are not recommended during immunosuppression.
Vaccines should be administered at least 2 weeks before immunosuppressive therapy (4 weeks if it is a live virus or bacteria vaccine), or they should be postponed until 3 months after completion of therapy (6 months if therapy contained B-cell-targeting monoclonal antibodies).
With few exceptions, caregivers and household contacts should be encouraged to obtain recommended vaccinations. Because some patients with cancer may be unable to mount a sufficient immune response to vaccines, vaccination of those around them may be the best available protection against vaccine-preventable illnesses.
Bridges CB. Ann Intern Med. 2014;160:190.
National Center for Immunization and Respiratory Diseases. MMWR Recomm Rep. 2011;60:993.
R