REVIEW
Human Vaccines & Immunotherapeutics 11:11, 2606--2614; November 2015; 2015 Taylor & Francis Group, LLC
Practical review of immunizations in adult
patients with cancer
Ella J Ariza-Heredia* and Roy F Chemaly
Department of Infectious Diseases; Infection Control and Employee Health; The University of Texas; MD Anderson Cancer Center; Houston, TX USA
Keywords: cancer, immunization, infection, prevention, vaccine
Compared with the general population, patients with cancer
in general are more susceptible to vaccine-preventable
infections, either by an increased risk due to the malignancy
itself or immunosuppressive treatment. The goal of
immunizations in these patients is therefore to provide
protection against these infections, and to decrease the number
of vulnerable patients who can disseminate these organisms.
The proper timing of immunization with cancer treatment is key
to achieving better vaccine protection. As the oncology eld
continues to advance, leading to better quality of life and longer
survival, immunization and other aspects of preventive
medicine ought to move to the frontline in the care of these
patients. Herein, we review the vaccines most clinically relevant
to patients with cancer, as well as special cases including
vaccines after splenectomy, travel immunization and
recommendations for family members.
General Recommendations
Treatment regimens for oncological diseases have evolved dra-
matically over the past years and continue to change with the
advent of new medications. Clinicians have become increasingly
aware of the risk of infection associated with the malignancy itself
and/or immunosuppressive therapies, including higher risk for
pneumococcus, influenza infection and hepatitis B among
others.1-4 In general, adults with oncological diseases should be
advised to adhere to standard recommended immunization sched-
ules, but they should avoid live vaccines while on immunosuppres-
sive therapy. Types of immunizations are review in Table 1.
The aim of this manuscript is to review the current evidence
and to elucidate the practical aspects of vaccination in patients
with oncological condition (excluding stem cell transplant recipi-
ents) and family members, providing useful immunization rec-
ommendations for primary care providers, infectious diseases
practitioners and oncologists.
Inactivated vaccines
In general, inactivated vaccines should be given at least 2
weeks before the initiation of chemotherapy or other immuno-
suppressive therapy to maximize the immune response.
*Correspondence to: Ella J Ariza-Heredia; Email: eariza@mdanderson.org
Submitted: 04/16/2015; Revised: 05/28/2015; Accepted: 06/10/2015
http://dx.doi.org/10.1080/21645515.2015.1062189
2606 Human Vaccines & Immunotherapeutics
Vaccination during chemotherapy or radiation therapy should be
avoided because antibody responses are suboptimal. However,
vaccination with inactivated vaccines during this period is not
harmful and appears to provide sero-protection against some
pathogens in some patients.5
Live attenuated vaccines
Live attenuated vaccines should be administered at least 4
weeks prior to immunosuppressive therapy.5,6 The recommenda-
tions by the Centers for Disease Control and the Infectious Dis-
eases Society of America (IDSA), is that vaccination after
chemotherapy should not occur until at least 3 months after the
discontinuation of the immunosuppressive therapy, except for
patients receiving regimens that include antiB-cell antibodies,
in which case, vaccination should be delayed for at least 6 months
after treatment.7 However, the treating physician should carefully
consider the use of live attenuated vaccines, as some other chemo-
therapy agents would cause immunosuppression for over 3
months.8,9
Vaccine efficacy
Vaccine efficacy, which is based on the reduction of infection
rates in a community, can be very difficult to assess in oncological
patients owing to a low incidence of infection (e.g., tetanus) or
the seasonality of infection (e.g., influenza).10 Most data on vac-
cination in cancer patients are from underpowered studies that
include patients with different cancers and chemotherapy treat-
ments and that use diverse definitions of vaccine response.6
Classically, vaccine response is measured by assessing pre- and
post-vaccination antibody titers (Immunoglobulin G), which
should be performed by the same laboratory. The precise meth-
ods used to measure vaccine response vary depending on the vac-
cine as well as the antibody titer cut-off level used to indicate
protection.11
Inactivated Vaccines
Influenza vaccine
Cancer patients are known to be at great risk for morbidity
secondary to influenza infection, including bacterial pneumonia
and respiratory insufficiency,12-14 and mortality, the rate of
which ranges from 9% to 33% depending on the underlying
malignancy.13 Therefore, influenza vaccination should be
offered to all cancer patients except those receiving intensive
Volume 11 Issue 11
Table 1. Mechanisms for acquiring immunity from vaccines
Type of Immunization Principle of Action
Non-replicating Based on toxoid, protein subunits, Tetanus, diphtheria, pertussis, poliomyelitis, Usually requires 35 doses; antibody titers
vaccines bacterial, antigens, or immunogenic
proteins obtained with recombinant,
technology.
Replicating live Produced by disabling the virulent Measles-mumps-rubella, varicella, intranasal Severe reactions are possible;
attenuated vaccines properties of a disease-producing virus
or bacterium
Passive immunization Antibodies are infused to provide short- Varicella Immunoglobulin, hepatitis B
term protection
chemotherapy (e.g., acute leukemia patients receiving induction
or consolidation therapy) or anti-B-cell antibodies. Family
members and other close contacts of patients with cancer
should also be vaccinated against influenza.5 The recommended
influenza vaccine in patients with cancer is the intramuscular
inactivated vaccine. Intranasal administered live attenuated
influenza vaccine (LAIV) is currently not recommended for
patients with cancer as there is scarce data on safety. To our
knowledge, only one study by Carr et al.15 has evaluated the
safety of LAIV in non-neutropenic children with cancer who
were classify as mild to moderately immunocompromised,
describing the live vaccine to be safe and immunogenic. How-
ever as there is a safe non-live vaccine alternative, the current
recommendations including ours are to avoid LAIV.
The timing of influenza vaccination in relation to chemother-
apy helps to determine the vaccines serological response. Influ-
enza is a seasonal disease, and waiting to give the vaccine until a
few months after chemotherapy may not be an option in some
clinical circumstances. For patients who are undergoing or who
are about to undergo chemotherapy, the best option may be to
administer the vaccine 2 weeks before or 2 weeks after chemo-
therapy or to administer the vaccine between chemotherapy
cycles, and trying to avoid giving the vaccine when the patients
white blood cell counts are at their nadir.16 The concurrent
administration of granulocyte-macrophage colony-stimulating
factor at the time of vaccination is not recommended, as it was
not found to have a positive effect on the serological response to
influenza vaccination.17
The efficacy of the influenza vaccine is typically assessed by
measuring hemagglutinin antibody titers. A serum antibody titer
of 40 or a 4-fold increase in the hemagglutinin titer is normally
considered protective in healthy individuals.18 Using these
parameters, several studies have shown that the vaccine response
varies depending on the cancer type. For instance, patients with
breast cancer19,20 or lung cancer21 have mean vaccine response
rates of 66% and 78%, respectively, which are similar to that of
the general population. On the other hand, patients with hema-
tological malignancies such as multiple myeloma have much
lower vaccine response rates, which range from 19% to 27%.22,23
To improve the immunogenicity of influenza vaccination,
researchers have developed new methods of delivering the vac-
cine, although none has become the standard of care. The first
such method is the use of a high-dose vaccine. In one study,
www.tandfonline.com Human Vaccines & Immunotherapeutics
Examples Comments
hepatitis B, inuenza, Haemophilus diminishes with time
inuenza, pneumococcus, meningococcus
inuenza, yellow fever, oral polio, oral transmission of live pathogen may
typhoid occur; most provide immunity with 1
dose
Protection diminishes after weeks or
immunoglobulin months
Safdar et al. compared adult non-Hodgkin lymphoma patients
who received a 45-mcg-influenza vaccine with those who received
a 135-mcg vaccine and reported response rates of 40% and 60%,
respectively; however, the study population was too small to
determine whether this difference was statistically significant.24
The authors also reported no difference in adverse reactions
between the regular-dose and high-dose groups,24 although
others have reported that the high-dose vaccine is associated with
increased local pain and myalgia.25 The second novel method of
delivering the influenza vaccine is the 2-shot influenza vaccine.
Lo et al. found that the vaccine response rate of patients who
received 2 doses (71%) was significantly higher than that of
patients who received one dose (42%; p D 0.006).26 In another
study, Cheng et al. reported sero-protection rates of 58.3% after
one dose and 100% after 2 doses among children who had com-
pleted chemotherapy or who were receiving maintenance chemo-
therapy.27 One of the caveats of the 2-dose vaccination strategy is
the compliance rate, which for healthy children is 9.1%60.1%
depending on age; adolescents tend to have lower compliance
rates.28,29
Several aspects, including the seasonality and variation of
influenza strains as well as difficulty achieving adequate statistical
power to identify significant differences between groups, limit
researchers ability to accurately assess the effectiveness of the
influenza vaccine. However, a recent meta-analysis described that
the rates of lower respiratory disease, hospitalization, and mortal-
ity among cancer patients who received the influenza vaccine
were significantly lower than those among cancer patients who
did not.30 Given this favorable risk-benefit profile, physicians
should make every effort to further increase the rate of influenza
vaccination.
Pneumococcal vaccine
Streptococcus pneumoniae infection may have serious implica-
tions in patients with cancer including a high risk for invasive
pneumococcal disease especially for patients with multiple
myeloma, lung cancer, chronic lymphocytic leukemia, and
lymphoma.31,32 However, owing to the low incidence of pneu-
mococcal infection among cancer patients, documenting the
effect of the pneumococcal vaccine in terms of reducing the
risk for invasive pneumococcal disease is very difficult. Studies
have suggested that the pneumococcal vaccine reduces the bur-
den of invasive pneumococcal disease and non-bacteremic
2607
pneumococcal pneumonia in both healthy adults and HIV-
positive patients.33,34 Therefore, as the risk for invasive pneu-
mococcal disease is higher in patients with oncological diseases,
pneumococcal vaccine should be offered to all patients with
cancer.5 As with the administration of other inactivated vac-
cines, the administration of the pneumococcal vaccine should
be avoided during cycles of intense chemotherapy because of
the anticipated poor immunogenic response; ideally, the vac-
cine should be given before the patient begins treatment.5
The two available pneumococcal vaccines are 1) the pneumo-
coccal 13-valent conjugated vaccine (PCV13), which recently
replaced the pneumococcal 7-valent conjugated vaccine (PCV7),
and 2) the pneumococcal 23-valent polysaccharide vaccine
(PPSV23). Low antibody response to PPSV23 has been described
in the general adult population35 as well as in patients with
hematologic malignancies, including multiple myeloma and lym-
phoma, reporting protective antibody levels in only 33%43% of
individuals.23,36,37 In a double-blind trial that compared a single
dose of PCV13 with PPSV23 in 831 pneumococcal vaccine naive
adults 6064 years of age, PCV13 achieved a greater functional
immune response than PPSV23 for the majority of serotypes cov-
ered by PCV13.35
In search for a better immunogenic response, studies of
patients with Hodgkin disease38 and HIV showed that sequential
vaccination with the conjugated vaccine (PCV7) followed by
PPSV23 1 year later elicited functional anti-pneumococcal
responses for many of the serotypes that were significantly greater
than those achieved using the polysaccharide vaccine alone.39,40
The authors concluded that the conjugate vaccine primes the
immune system to provide an antibody response to the polysac-
charide pneumococcal vaccine. In 2013, the Advisory Committee
on Immunization Practices (ACIP) and the Centers for Disease
Control and Prevention expanded their recommendations for
the pneumococcal vaccination of unvaccinated, immunocompro-
mised patients age 19 years or more to include the administra-
tion of PCV13 followed by the administration of PPSV23 8
weeks later (Table 2).33 In the case of patients after stem cell
transplant, the recommendation is to use repeated doses of
the pneumococcus-conjugated vaccine to maintain durable
responses.6 Repeated doses of PPSV23 administered at intervals
of less than 5 years result in lower antibody levels in the general
population; this phenomenon is known as hypo-responsiveness
and is caused by the depletion of polysaccharide-specific B cells.41
Earlier randomized studies of pneumococcal vaccination had
been underpowered to evaluate the efficacy against community-
acquired pneumonia secondary to the vaccine strains;34 however
a recent multicenter study including almost 85,000 participants
65 years or older evaluating the effectiveness of PCV13 demon-
strated how the vaccine offers moderate protection against the
most common forms of pneumococcal community-acquired
pneumonia in healthy elderly people. Over 42,500 senior citizens
were vaccinated with the PCV13 from September 2008 to the
end of January 2010 and the same number received a placebo. In
their analysis of infections due to vaccine-type strains, commu-
nity-acquired pneumonia occurred in 49 and 90 adults in the
PCV13 and the placebo groups, respectively (vaccine efficacy,
2608 Human Vaccines & Immunotherapeutics
Table 2. Centers for Disease Control and Prevention Recommendations
for pneumococcal vaccination in immunocompromised patients age
19-64 years and asplenic patients33
Patient Vaccination Recommendations
Status
Unvaccinated A single dose of PCV13 should be given, followed
by a single dose of PPSV23 at least 8 weeks
later.
At least 1 dose of A single dose of PCV13 should be given if 1 or
PPSV23 received more years have passed after the last dose of
PPSV23.
Additional doses of The rst additional dose of PPSV23 should be given
PPSV23 required at least 8 weeks after the most recent dose of
PCV13 and at least 5 years after the most recent
dose of PPSV23.
Abbreviations: PCV13 (pneumococcal conjugated vaccine), PPSV23
(pneumococcal polysaccharide vaccine).
45.6%; 95.2% confidence interval [CI], 21.8 to 62.5) and inva-
sive pneumococcal disease occurred in 7 and 28 adults in the
PCV13 and the placebo groups, respectively (vaccine efficacy,
75.0%; 95% CI, 41.4 to 90.8).42 The results of this study are
encouraging and maybe applied to mild to moderately immuno-
compromised patients.
Tetanus, diphtheria, and pertussis vaccine
Bordetella pertussis causes a highly contagious upper respira-
tory infection known as whooping cough. Rare but serious com-
plications can include pneumonia, encephalopathy, and seizures
have been reported,43 and immunocompromised patients are
vulnerable to serious, often fatal, complications.44 Moreover, in
recent years, there has been a considerable increase in the cases of
pertussis, with reports from California in 2010 of over 9,000
cases and 10 infant deaths.45 The evaluation of serological evi-
dence of immunity in patients with cancer has demonstrated a
waning of immunity for Tetanus, diphtheria and acellular pertus-
sis (Tdap) after chemotherapy. In a report by Hammarstrom
et al. in patients after autologous transplantation, less than 50%
of subjects had antibodies against tetanus, diphtheria, and pertus-
sis.46 Therefore, given that Tdap immunity may diminish over
time, and the recent increase in pertussis cases,45 a booster Tdap
vaccination should be considered for patients who have com-
pleted chemotherapy.5,43
Hepatitis B vaccine
In patients who receive cytotoxic chemotherapy, inactivated
Hepatitis B virus (HBV) may reactivate and result in varying
degrees of liver damage. The rate of HBV reactivation in cancer
patients receiving chemotherapy can be as high as 47%.47 Fur-
thermore, immunosuppressed patients are more likely to remain
chronically infected with HBV; among cancer patients, the rate
of chronic HBV infection ranges from 18% to 26%, and HBV
infectionrelated mortality up to 5%.48,49 In addition, the loss of
pre-existing immunity to HBV has been described in up to 50%
of patients who have undergone stem cell transplant. In patients
Volume 11 Issue 11
who have received chemotherapy,50 especially antiB-cell anti-
bodies such as rituximab, the loss of such immunity can result in
virus re-emergence with or without signs of hepatitis.51 There-
fore, HBV status should be determined, and the immunization
of susceptible patients strongly considered, at the time of cancer
diagnosis.47 The HBV vaccine response rate of cancer patients
receiving chemotherapy was reported in a study by Weitberg
et al. to be more than 70% of individuals, which has been
described as adequate.52
Meningococcal vaccine
Patients with cancer should follow the ACIP recommenda-
tions for meningococcal vaccine including adolescents, individu-
als with persistent complement component deficiency (e.g.,
C5C9, properidin, factor H, or factor D) and functional or ana-
tomic asplenia, and for adolescents with HIV infection. Similar
to other non-live vaccines, meningococcal vaccine should be
offered either prior to chemotherapy or once patients immune
system has recovered.53 Patients who underwent radiation to
the spleen and are considered to have functional asplenia54 (i.e. if
the patient has received doses greater than 30 Gy during radia-
tion) should also be offered meningococcal vaccine following
meningococcal vaccine recommendations for splenectomized
patients (please see below recommendations for splenectomized
patients). In terms of immune responses to the vaccine, a study
by Yu et al. in pediatric patients with acute lymphocytic leuke-
mia evaluated antibody response to meningococcal C-conjugate
vaccine after chemotherapy and showed variable responses which
are related to proximity to chemotherapy and total number of B
cells.55
Human papillomavirus vaccine
Human papillomavirus (HPV) is associated with the develop-
ment of genital warts, anogenital cancers (including cervical, vag-
inal, vulvar, and anal), and oropharyngeal cancer. The ACIP and
the Centers for Disease Control and Prevention recommends
that HPV vaccination should be routinely given to females and
males aged 11 years or 12 years old. For those not vaccinated at
the target age, catch-up vaccination is recommended up to age
26 years.56 The presence of immunosuppression is not a contra-
indication to HPV vaccination, and current recommendations
are to follow the general vaccination schedule by the ACIP.5
However, the immune response may be less robust in the immu-
nocompromised patient.57
Hepatitis A vaccine
Immunization against Hepatitis A virus (HAV) infection
should be offered to patients with cancer traveling to countries
endemic for this virus, as well as for household or close contacts
with an individual with an acute HAV infection, men who have
sex with men, illicit drug users, populations or communities that
have high endemic rates of HAV infections (also discussed in the
Travel section), or are at risk of HAV outbreaks and household
or close contact with children adopted from endemic countries
for HAV. Primary immunization can be achieved with one dose
www.tandfonline.com Human Vaccines & Immunotherapeutics
of HAV vaccine with a booster dose given 6 to 36 months
later.58,59
The immunological response to HAV vaccine in immuno-
compromised patients with cancer has not been systematically
assessed. In a study including solid organ transplant recipients,
Gunther et al. evaluated sero-conversion following 2 doses of the
HAV vaccine in kidney and liver transplant recipients and found
significant sero-conversion rates in 72% and 97% of patients
respectively, versus 100% in healthy controls. However, after
2 years, immunity persisted in 26%59% of the transplant recip-
ients vs. 100% of the healthy controls;60 thus reassessment of
immunity may be indicated later on in specific situations.
Live Attenuated Vaccines
Unlike inactivated vaccines, live attenuated vaccines may pose
a risk of replication of the virus after administration, and live vac-
cines can actually induce infection in immunocompromised
patients.6 Therefore, physicians should carefully evaluate and dis-
cuss these vaccines risk-benefit profile with their patients before
making a recommendation regarding their use. Live attenuated
vaccines could be administered at least 4 weeks before the initia-
tion of highly immunosuppressive therapy and at least 3 months
after the completion of chemotherapy; the timing of vaccination
after chemotherapy may be much later depending on the immu-
nosuppressive agents used.8
Varicella and zoster vaccines
Varicella zoster virus (VZV) commonly causes chickenpox in
children, but it may also be seen in adults, in whom it generally
can cause morbidity and mortality, especially in immunocom-
promised patients. The most common presentation is referred to
as shingles, and other rare complications include meningoen-
cephalitis, cerebellitis, herpes zoster ophthalmicus, and Ramsay
Hunt syndrome.30
Although the risk for varicella zoster due to vaccination is
low,61 varicella infection associated with the vaccine can occur in
patients with cancer, and the infection ranges from mild to mod-
erately severe.62 To our knowledge, death has been reported in 2
different instances, one of a child who received the vaccine while
undergoing consolidation chemotherapy,63 and a recent report
by Bhalla et al. of disseminated, fatal infection in an adult 4 years
after transplantation and who had been diagnosed with a new
low-grade lymphoma.64
Therefore, the need for varicella vaccination after chemother-
apy should be evaluated with caution. Vaccine seroprotection has
been evaluated in children with leukemia in remission by Leung
et al. who reported seroconversion rates to Varicella vaccine
(Varivax, Merck, USA) of 88% after the first dose and 98% after
the second dose.62
In terms of Zoster vaccine (Zostavax, Merck, USA), this vac-
cine is recommended as a 1-time vaccination in individuals aged
60 years or older, and although it is clear that immunosuppres-
sion increases the risk of herpes zoster, there is a paucity of studies
aimed at understanding the benefits and risks of administering
2609
this vaccine in this special population.59 Tseng et al. recently
reported how older patients who receive the zoster vaccine were
likely to continue to derive its benefits even if they become
immunosuppressed; however, the study was not able to deter-
mine zoster vaccine safety or effectiveness in cancer patients who
received zoster vaccine less than 60 days before beginning che-
motherapy.65,66 This study emphasizes the need to vaccinate
immunocompetent patients older than 60 years of age, as cur-
rently no recommendations can be done about Zostavax vaccina-
tion in immunocompromised individuals.
Measles, mumps, and rubella vaccine
Morbidity and mortality rates by measles can be high in
patients with cancer.67,68 In a study in Britain over 11 years
including 1043 children with acute lymphoblastic leukemia; 51
children (4.9%) died while in first remission, and 15 (29.4%) of
these deaths were due to measles or its complications: 10 cases of
pneumonia, and 5 cases of encephalitis.69 Furthermore, Feldman
et al. showed declining rates of antibody seropositivity of previ-
ously immunized children for measles, mumps, and rubella
between 64% 77%, after receiving treatment for acute leukemia
or acute lymphoid leukemia,70 emphasizing the need to reevalu-
ate measles immunity after chemotherapy.
Recent outbreaks of measles have been reported in the United
States and overseas.71 Although the measles-mumps-rubella
(MMR) vaccine is live attenuated and should not be adminis-
tered to severely immunocompromised patients, it might be con-
sidered in patients after chemotherapy that are at an increased
risk for measles. With reference to vaccine response, Patel et al.
reported antibody response to MMR vaccine in more than 94%
of children who had completed standard chemotherapy for acute
leukemia, without adverse reactions.72
Special Considerations in Splenectomized Patients
Anatomic or functional asplenia is frequently encountered in
patients with cancer. Patients with asplenia have an increased risk
for fulminant bacteremia and septicemia caused by encapsulated
bacteria, which is associated with a high mortality.73 In a popula-
tion-based study in Sweden that included 20,000 patients who
underwent splenectomy between 1970 and 2009, the risk of hospi-
talization or death from sepsis among these patients who underwent
splenectomy for a hematologic malignancy was higher than that
among patients who underwent spleen removal due to trauma.74
Patients should undergo vaccination at least 2 weeks prior to
an elective splenectomy.75 For patients who receive vaccines after
splenectomy, the antibody response to the immunizations should
be measured to determine the need for booster doses, as studies
in children with Hodgkin disease showed poor antibody response
to vaccines given after splenectomy.76 Compared with those of
healthy individuals, the immune systems of patients with hypo-
splenia can mount only a small protective antibody response to
polysaccharide antigens, which may result in vaccine failure.
Therefore, conjugated vaccines are preferred in these patients.
2610 Human Vaccines & Immunotherapeutics
The current recommended vaccines in patients immediately
before or after splenectomy are vaccines against pneumococcus,
Neisseria meningitidis (meningococcus), and Haemophilus influen-
zae type b.
Pneumococcal vaccine
Recommendations for pneumococcus vaccine for splenectom-
ized patients are depicted in Table 2. Adults who have under-
gone splenectomy should be revaccinated with one dose of the
pneumococcus polysaccharide vaccine 5 years after the initial
immunization.77
Meningococcal vaccine
In splenectomy patients receiving meningococcal vaccination,
the immunity provided by the conjugate vaccine (Menveo,
Novartis, USA, or Menactra, Sanofi-Pasteur, France) is expected
to be higher and longer lasting than that provided by the polysac-
charide quadrivalent meningococcal vaccine (Menomune A/C/Y/
W-135, Sanofi-Pasteur, France). Although the quadrivalent
meningococcal polysaccharide vaccine is the only meningococcal
vaccine approved by the US. Food and Drug Administration for
asplenic patients age 56 years or more,78,79 patients who have
undergone splenectomyeven those age 56 years or more
should receive the quadrivalent conjugate meningococcal vac-
cine.80 This recommendation is supported by data showing that
in individuals who previously received a meningococcal conju-
gate vaccine, antibody responses to a subsequent dose of the same
vaccine were higher than those to a subsequent dose of the poly-
saccharide quadrivalent vaccine.81 Two new serogroup B menin-
gococcal vaccines (Bexsero, Novartis, USA, and Trumenba,
Pfizer, USA) that have been approved recently by the US. Food
and Drug Administration for patients 10 to 25 years old should
also be considered in asplenic patients.
Revaccination with conjugated meningococcal vaccine every
5 years is recommended for previously vaccinated adults who
remain at an increased risk for infection (e.g., adults with ana-
tomic or functional asplenia or persistent complement compo-
nent deficiencies).
Haemophilus influenza b vaccine
Asplenic patients and those planned to undergo elective sple-
nectomy should receive one dose of Haemophilus influenza b
vaccine (Hib) or any Hib-containing vaccine. The Hib conjugate
vaccine has been shown to be immunogenic in both children and
adults who have undergone splenectomy.82,83 Data on revaccina-
tion against Hib are not available.
Other Considerations
Travel
Immunocompromised cancer patients who wish to travel out-
side the United States should be referred to a travel medicine spe-
cialist who is familiar with their care and medications.
Depending on the area the patient plans to visit, the pre-travel
visit should include a discussion about the vaccines the patient
Volume 11 Issue 11
should receive before departing (i.e., Hepatitis A, typhoid fever,
polio), and steps the patient can take to reduce the risk of con-
tracting nonvaccine-preventable illnesses such as malaria, and
food- or water-borne illnesses.59
Hepatitis A, intramuscular/subcutaneous polio and Vi capsu-
lar polysaccharide (ViCPS) are inactive vaccines, therefore con-
sidered safe in immunocompromised patients (see Hepatitis A
section). Oral polio and oral typhoid vaccines (Ty21a) are
live-attenuated vaccines and should not be administered in
immunocompromised patients. If time does not permit adequate
vaccination (e.g., patient presents 2 weeks prior to travel), con-
sider administering gamma globulin alone or in combination
with hepatitis A vaccine.84
Patients actively receiving chemotherapy should be discour-
aged from traveling to high-infection-risk areas such as regions
where yellow fever is endemic, locations with active disease out-
breaks, and regions with limited health care facilities.85
general, inactivated vaccines, the MMR vaccine, and vaccine
against yellow fever are safe. Live attenuated zoster vaccine (Zos-
tavax, Merck USA) and varicella vaccine (Varivax, Merck Inc.,
USA) are also safe; however, immunocompromised patients
should avoid contact with persons who develop skin lesions after
receipt of these vaccines until such lesions clear or crust. Other
vaccines require caution on the part of the patient and household
members. For example, patients with severe neutropenia and
those who have received a stem cell transplant should avoid con-
tact with household members who have recently received the
nasal influenza vaccine. Also, as oral rotavirus vaccine is live
attenuated and the virus may persists in feces, thus immunocom-
promised patients should avoid contact with the soiled diapers of
infants who have received the rotavirus vaccine for 46 weeks.
The oral polio vaccine should not be administered to household
members. There is not enough data for oral typhoid or cholera
vaccine to make any recommendations.

Household contacts Compliance

Patients family members should remain up-to-date with their
vaccinations as per the Centers for Disease Control and Preven-
tion/Advisory Committee on Immunization Practices guidelines.
However, some caveats regarding vaccination in households that
include immunocompromised patients should be considered. In
Common barriers to vaccination include a lack of access to
medical care and patients concerns about vaccine safety. Immu-
nization rates remain low in patients with cancer. In one survey
study conducted at a university-based outpatient cancer treat-
ment clinic, of the 204 cancer patients who completed the survey,

Table 3. Practical vaccination recommendations in patients with cancer

Dosing Schedule Considerations Contraindications

Inuenza Seasonal Administration of indicated inactivated vaccines 2 or Severe allergic reaction (e.g., anaphylaxis) after
more weeks prior to chemotherapy is preferred. previous dose of any inuenza vaccine; or to a
vaccine component, including egg protein
Pneumococcus Recommended Table 2 Severe allergic reaction (e.g., anaphylaxis) after a
previous dose or to a vaccine component,
including to any vaccine containing diphtheria
toxin
Td/Tdap Booster Replace a Td booster for Tdap An immediate anaphylactic reaction. Encephalopathy
occurring within 7 days following DTP vaccination
Hepatitis B 3 doses at 0,1 and 6 months All patients should be screened for immunity, and History of hypersensitivity to yeast or any vaccine
vaccinated as needed. Consider antibody component
measurement after last vaccine.
Hib Recommended for If patient is unimmunized, a dose of Hib should be Some of the combined Hib vaccines, such Hiberix,
splenectomized patients. offered after chemotherapy ActHib might contain natural rubber latex, which
Others, usual may cause allergy in latex sensitive persons.
recommendations
Meningococcus Splenectomized patients. For international travelers, vaccination is Vaccination with MenACWY, MPSV4, or Hib-MenCY-TT
Others, usual recommended for those visiting the parts of sub- is contraindicated among persons known to have a
recommendations Saharan Africa known as the meningitis belt severe allergic reaction to any component of the
during the dry season (DecemberJune). vaccine, including diphtheria or tetanus toxoid
Hepatitis A Usual recommendations Consider antibody testing in case of future exposure Contraindicated if history of previous allergy to the
(see text). after 2-3 years post-vaccination. vaccine or a component of the vaccine
MMR CAUTION May be considered in specic cases at least 3-6 Contraindicated while on chemotherapy or
months after chemotherapy (i.e. children not radiotherapy
vaccinated or epidemiological situation).
Recommend checking antibody level prior.
Varicella/Zoster CAUTION May be considered in children not previously Contraindicated if given <4 weeks of starting
vaccinated, at least 3-6 months after chemotherapy chemotherapy .No data is available after
is nished (see text). There is no data for Zoster chemotherapy
vaccination after chemotherapy.

Abbreviations: Td/Tdap (Tetanus diphtheria/ Tetanus/diphtheria/acellular pertussis), DTP (diphtheria, tetanus, and pertussis), MMR (Measles, mumps and
rubella), Hib (Heamophilus b conjugated vaccine), Hiberix (GlaxoSmithKline, England), ActHib (Sano-Pasteur, France).

www.tandfonline.com Human Vaccines & Immunotherapeutics 2611

30% had never received an influenza vaccine, 56% had never
received a pneumococcal vaccine, and only 7% remembered their
oncologist asking or informing them about vaccination.86 Other
studies have reported low vaccination rates among splenectom-
ized patients; however, these rates varied depending on the vac-
cine: whereas the rate of pneumococcal vaccination was 85.4%,
those of Hib vaccination and meningococcal vaccination were
only 39.4% and 32.3%, respectively.87,88 As patients with cancer
are in constant contact with the healthcare system and have great
trust in their healthcare providers, continuous efforts to evaluate
and improve vaccination compliance are highly encouraged. This
should be a joint mission between oncologist and primary care
provider, in consultation with infectious diseases physician and
pharmacist for complicated cases.
Conclusions
strongly encouraged to discuss vaccinations and other aspects of
preventive medicine with their patients. New vaccines are in
development including recombinant CMV vaccine, inactivated
zoster vaccine that might give new possibilities to prevent these
specific and common infections in immunocompromised hosts.
Several questions remain unanswered including evaluation of
immunogenicity on patients undergoing new target chemother-
apy agents, and the need for long-term boosters. Prospective-
multicenter clinical trials need to be performed to better assess
the efficacy of vaccination, evaluation of immunogenicity in
patients undergoing new-targeted chemotherapy, as well as the
establishment of a registry to provide safety data.
Disclosure of Potential Conflicts of Interest
R.F.C. has received research funding from GlaxoSmithKline.
E.J. A-H. declares no conflict of interest.

Patients with oncological diagnosis and undergoing chemo-

therapy, have in general higher risks of infection. Many of these Acknowledgments
infections can be prevented by vaccinations (Table 3). As cancer We thank Mr. Joseph Munch, Scientific publications, for his
treatments improve, eliciting better outcomes, practitioners are editorial revision of the article.

References
1. Meisel R, Toschke AM, Heiligensetzer C, Dilloo D,
Laws HJ, von Kries R. Increased risk for invasive pneu-
mococcal diseases in children with acute lymphoblastic
leukaemia. Br J Haematol 2007; 137:457-60;
PMID:17488489; http://dx.doi.org/10.1111/j.1365-
2141.2007.06601.x
2. Wong A, Marrie TJ, Garg S, Kellner JD, Tyrrell
GJ, Group S. Increased risk of invasive pneumococ-
cal disease in haematological and solid-organ malig-
nancies. Epidemiol Infect 2010; 138:1804-10;
PMID:20429967; http://dx.doi.org/10.1017/
S0950268810000919
3. Chemaly RF, Vigil KJ, Saad M, Vilar-Compte D, Cor-
nejo-Juarez P, Perez-Jimenez C, Mubarak S, Salhab M,
Jiang Y, Granwehr B, et al. A multicenter study of pan-
demic influenza A (H1N1) infection in patients with
solid tumors in 3 countries: early therapy improves out-
comes. Cancer 2012; 118:4627-33; PMID:22359314;
http://dx.doi.org/10.1002/cncr.27447
4. Kwon HJ, Lee JW, Chung NG, Cho B, Kim HK, Kang
JH. Assessment of serologic immunity to diphtheria-
tetanus-pertussis after treatment of Korean pediatric
hematology and oncology patients. J Korean Med Sci
2012; 27:78-83; PMID:22219618; http://dx.doi.org/
10.3346/jkms.2012.27.1.78
5. Rubin LG, Levin MJ, Ljungman P, Davies EG, Avery
R, Tomblyn M, Bousvaros A, Dhanireddy S, Sung L,
Keyserling H, et al. 2013 IDSA clinical practice guide-
line for vaccination of the immunocompromised host.
Clin Infect Dis 2014; 58:309-18; PMID:24421306;
http://dx.doi.org/10.1093/cid/cit816
6. Ljungman P. Vaccination of immunocompromised
patients. Clin Microbiol Infect 2012; 18(Suppl 5):93-
9; PMID:23051059; http://dx.doi.org/10.1111/
j.1469-0691.2012.03971.x
7. Berglund A, Willen L, Grodeberg L, Skattum L, Hagberg
H, Pauksens K. The response to vaccination against influ-
enza A(H1N1) 2009, seasonal influenza and Streptococ-
cus pneumoniae in adult outpatients with ongoing
treatment for cancer with and without rituximab. Acta
Incol 2014; 53:1212-20; PMID:24865118; http://dx.doi.
org/10.3109/0284186X.2014.914243
8. Bracci L, Schiavoni G, Sistigu A, Belardelli F. Immune-
based mechanisms of cytotoxic chemotherapy: implica-
tions for the design of novel and rationale-based
combined treatments against cancer. Cell Death Differ-
ent 2014; 21:15-25; PMID:23787994; http://dx.doi.
org/10.1038/cdd.2013.67
9. Schwarzberg AB, Stover EH, Sengupta T, Michelini A,
Vincitore M, Baden LR, Kulke MH. Selective lympho-
penia and opportunistic infections in neuroendocrine
tumor patients receiving temozolomide. Cancer Invest
2007; 25:249-55; PMID:17612935; http://dx.doi.org/
10.1080/07357900701206380
10. Kotton CN, Poznansky MC. Vaccination of oncology
patients: an effective tool and an opportunity not to be
missed. Oncologist 2012; 17:1-2; PMID:22240542;
http://dx.doi.org/10.1634/theoncologist.2011-0383
11. Balmer P, Cant AJ, Borrow R. Anti-pneumococcal
antibody titre measurement: what useful information
does it yield? J Clin Pathol 2007; 60:345-50;
PMID:16950855; http://dx.doi.org/10.1136/
jcp.2006.041210
12. Couch RB, Englund JA, Whimbey E. Respiratory viral
infections in immunocompetent and immunocompro-
mised persons. Am J Med 1997; 102:2-9; discussion
256; PMID:10868136; http://dx.doi.org/10.1016/
S0002-9343(97)00003-X
13. Schepetiuk S, Papanaoum K, Qiao M. Spread of influ-
enza A virus infection in hospitalised patients with can-
cer. Aust N Z J Med 1998; 28:475-6; PMID:9777122;
http://dx.doi.org/10.1111/j.1445-5994.1998.tb02089.x
14. Advisory Committee on Immunization P. Prevention
and control of influenza with vaccines: interim recom-
mendations of the advisory committee on immuniza-
tion practices (ACIP), 2013. MMWR Morb Mortal
Wkly Rep 2013; 62:356; PMID:23657110
15. Carr S, Allison KJ, Van De Velde LA, Zhang K,
English EY, Iverson A, Daw NC, Howard SC, Navid
F, Rodriguez-Galindo C, et al. Safety and immunoge-
nicity of live attenuated and inactivated influenza vac-
cines in children with cancer. J Infect Dis 2011;
204:1475-82; PMID:21949042; http://dx.doi.org/
10.1093/infdis/jir561
16. Matsuzaki A, Suminoe A, Koga Y, Kinukawa N, Kusu-
hara K, Hara T. Immune response after influenza vacci-
nation in children with cancer. Pediatr Blood Cancer
2005; 45:831-7; PMID:16007602; http://dx.doi.org/
10.1002/pbc.20470
17. Pauksen K, Linde A, Hammarstrom V, Sjolin J, Carne-
skog J, Jonsson G, Oberga G, Engelmann H, Ljung-
man P. Granulocyte-macrophage colony-stimulating
factor as immunomodulating factor together with influ-
enza vaccination in stem cell transplant patients. Clin
Infect Dis 2000; 30:342-8; PMID:10671339; http://
dx.doi.org/10.1086/313663
18. Molinari NA, Ortega-Sanchez IR, Messonnier ML,
Thompson WW, Wortley PM, Weintraub E, Bridges
CB. The annual impact of seasonal influenza in the US:
measuring disease burden and costs. Vaccine 2007;
25:5086-96; PMID:17544181; http://dx.doi.org/
10.1016/j.vaccine.2007.03.046
19. Brydak LB, Guzy J, Starzyk J, Machala M, Gozdz SS.
Humoral immune response after vaccination against
influenza in patients with breast cancer. Support Care
Cancer 2001; 9:65-8; PMID:11147146; http://dx.doi.
org/10.1007/s005200000186
20. Meerveld-Eggink A, de Weerdt O, van der Velden AM,
Los M, van der Velden AW, Stouthard JM, Nijziel
MR, Westerman M, Beeker A, van Beek R, et al.
Response to influenza virus vaccination during chemo-
therapy in patients with breast cancer. Ann Oncol
2011; 22:2031-5; PMID:21303799; http://dx.doi.org/
10.1093/annonc/mdq728
21. Anderson H, Petrie K, Berrisford C, Charlett A,
Thatcher N, Zambon M. Seroconversion after influ-
enza vaccination in patients with lung cancer. Br J Can-
cer 1999; 80:219-20; PMID:10389999; http://dx.doi.
org/10.1038/sj.bjc.6690342
22. Goossen GM, Kremer LC, van de Wetering MD.
Influenza vaccination in children being treated with
chemotherapy for cancer. Cochrane Database Syst
Rev. 2009 Apr 15;(2):CD006484. http://dx.doi.org/
10.1002/14651858.CD006484.pub2
23. Robertson JD, Nagesh K, Jowitt SN, Dougal M,
Anderson H, Mutton K, Zambon M, Scarffe JH.
Immunogenicity of vaccination against influenza,
Streptococcus pneumoniae and Haemophilus influen-
zae type B in patients with multiple myeloma. Br J
Cancer 2000; 82:1261-5; PMID:10755398; http://dx.
doi.org/10.1054/bjoc.1999.1088
24. Safdar A, Rodriguez MA, Fayad LE, Rodriguez GH,
Pro B, Wang M, Romaguera JE, Goy AH, Hage-
meister FB, McLaughlin P, et al. Dose-related safety
and immunogenicity of baculovirus-expressed triva-
lent influenza vaccine: a double-blind, controlled
trial in adult patients with non-Hodgkin B cell lym-
phoma. J Infect Dis 2006; 194:1394-7;

2612 Human Vaccines & Immunotherapeutics Volume 11 Issue 11

 PMID:17054068; http://dx.doi.org/10.1086/
508493
25. Couch RB, Winokur P, Brady R, Belshe R, Chen WH,
Cate TR, Sigurdardottir B, Hoeper A, Graham IL,
Edelman R, et al. Safety and immunogenicity of a high
dosage trivalent influenza vaccine among elderly sub-
jects. Vaccine 2007; 25:7656-63; PMID:17913310;
http://dx.doi.org/10.1016/j.vaccine.2007.08.042
26. Lo W, Whimbey E, Elting L, Couch R, Cabanillas F,
Bodey G. Antibody response to a two-dose influenza
vaccine regimen in adult lymphoma patients on chemo-
therapy. Eur J Clin Microbiol Infect Dis 1993; 12:778-
82; PMID:8307050; http://dx.doi.org/10.1007/
BF02098469
27. Cheng FW, Chan PK, Leung WK, Lee V, Shing MK,
Yeung AC, Li CK. Pandemic (H1N1) 2009 vaccine in
paediatric oncology patients: one dose or two doses? Br
J Haematol 2011; 154:408-9; PMID:21488856;
http://dx.doi.org/10.1111/j.1365-2141.2010.08501.x
28. Centers for Disease C, Prevention. Influenza vaccina-
tion coverage among children aged 6 months18 years
- eight immunization information system sentinel sites,
United States, 2008-09 influenza season. MMWR
Morb Mortal Wkly Rep 2009; 58:1059-62;
PMID:19798018
29. Pabst LJ, Chaves SS, Weinbaum C. Trends in compli-
ance with two-dose influenza vaccine recommendations
among children aged 6 months through 8 years. Vac-
cine 2013; 31:3116-20; PMID:23684827; http://dx.
doi.org/10.1016/j.vaccine.2013.04.080
30. Cheuk DK, Chiang AK, Lee TL, Chan GC, Ha SY.
Vaccines for prophylaxis of viral infections in patients
with hematological malignancies. Cochrane Database
Syst Rev. 2011 Mar 16;(3):CD006505. http://dx.doi.
org/10.1002/14651858.CD006505.pub2.
31. Lipsky BA, Boyko EJ, Inui TS, Koepsell TD. Risk fac-
tors for acquiring pneumococcal infections. Arch Intern
Med 1986; 146:2179-85; PMID:3778047; http://dx.
doi.org/10.1001/archinte.1986.00360230105016
32. Itala M, Helenius H, Nikoskelainen J, Remes K. Infec-
tions and serum IgG levels in patients with chronic
lymphocytic leukemia. Eur J Haematol 1992; 48:266-
70; PMID:1644158; http://dx.doi.org/10.1111/
j.1600-0609.1992.tb01805.x
33. Centers for Disease C, Prevention. Use of 13-valent
pneumococcal conjugate vaccine and 23-valent pneu-
mococcal polysaccharide vaccine for adults with immu-
nocompromising conditions: recommendations of the
advisory committee on immunization practices (ACIP).
MMWR Morb Mort Wkly Rep 2012; 61:816-9;
PMID:23051612
34. French N, Gordon SB, Mwalukomo T, White SA,
Mwafulirwa G, Longwe H, Mwaiponya M, Zijlstra
EE, Molyneux ME, Gilks CF. A trial of a 7-valent
pneumococcal conjugate vaccine in HIV-infected
adults. N Engl J Med 2010; 362:812-22;
PMID:20200385; http://dx.doi.org/10.1056/
NEJMoa0903029
35. Jackson LA, Gurtman A, van Cleeff M, Jansen KU,
Jayawardene D, Devlin C, Scott DA, Emini EA,
Gruber WC, Schmoele-Thoma B. Immunogenicity
and safety of a 13-valent pneumococcal conjugate vac-
cine compared to a 23-valent pneumococcal polysac-
charide vaccine in pneumococcal vaccine-naive adults.
Vaccine 2013; 31:3577-84; PMID:23688526; http://
dx.doi.org/10.1016/j.vaccine.2013.04.085
36. Hinge M, Ingels HA, Slotved HC, Molle I. Serologic
response to a 23-valent pneumococcal vaccine adminis-
tered prior to autologous stem cell transplantation in
patients with multiple myeloma. APMIS 2012;
120:935-40; PMID:23009118; http://dx.doi.org/
10.1111/j.1600-0463.2012.02922.x
37. Sinisalo M, Vilpo J, Itala M, Vakevainen M, Taurio J,
Aittoniemi J. Antibody response to 7-valent conjugated
pneumococcal vaccine in patients with chronic lym-
phocytic leukaemia. Vaccine 2007; 26:82-7;
PMID:18053620; http://dx.doi.org/10.1016/j.vaccine.
2007.10.053
www.tandfonline.com
38. Chan CY, Molrine DC, George S, Tarbell NJ, Mauch
P, Diller L, Shamberger RC, Phillips NR, Goorin A,
Ambrosino DM. Pneumococcal conjugate vaccine
primes for antibody responses to polysaccharide pneu-
mococcal vaccine after treatment of Hodgkins disease.
J Infect Dis 1996; 173:256-8; PMID:8537671; http://
dx.doi.org/10.1093/infdis/173.1.256
39. Greenberg RN, Gurtman A, Frenck RW, Strout C,
Jansen KU, Trammel J, Scott DA, Emini EA, Gruber
WC, Schmoele-Thoma B. Sequential administration of
13-valent pneumococcal conjugate vaccine and 23-val-
ent pneumococcal polysaccharide vaccine in pneumo-
coccal vaccine-naive adults 60-64 years of age. Vaccine
2014; 32:2364-74; PMID:24606865; http://dx.doi.
org/10.1016/j.vaccine.2014.02.002
40. Glesby MJ, Watson W, Brinson C, Greenberg RN,
Lalezari JP, Skiest D, et al. Immunogenicity and safety
of 13-valent pneumococcal conjugate vaccine in
HIVinfected adults previously vaccinated with pneu-
mococcal polysaccharide vaccine. J Infect Dis 2015 Jul
1; 212(1):18-27
41. Pollard AJ, Perrett KP, Beverley PC. Maintaining pro-
tection against invasive bacteria with protein-polysac-
charide conjugate vaccines. Nat Rev Immunol 2009;
9:213-20; PMID:19214194; http://dx.doi.org/
10.1038/nri2494
42. Bonten MJ, Huijts SM, Bolkenbaas M, Webber C, Pat-
terson S, Gault S, van Werkhoven CH, van Deursen
AM, Sanders EA, Verheij TJ, et al. Polysaccharide con-
jugate vaccine against pneumococcal pneumonia in
adults. N Engl J Med 2015; 372:1114-25;
PMID:25785969; http://dx.doi.org/10.1056/
NEJMoa1408544
43. Florax A, Ehlert K, Becker K, Vormoor J, Groll AH.
Bordetella pertussis respiratory infection following
hematopoietic stem cell transplantation: time for uni-
versal vaccination? Bone Marrow Transplant 2006;
38:639-40; PMID:16964268; http://dx.doi.org/
10.1038/sj.bmt.1705495
44. Senturk E, Sen S, Telli M. Empyema due to Bordetella
pertussis in an adult patient with lung cancer. Arch De
Bronconeumol 2012; 48:263-4; PMID:22503592;
http://dx.doi.org/10.1016/j.arbr.2012.04.002
45. Winter K, Glaser C, Watt J, Harriman K, Centers for
Disease C, Prevention. Pertussis epidemicCalifornia,
2014. MMWR Morb Mort Wkly Rep 2014; 63:1129-
32; PMID:25474033
46. Hammarstrom V, Pauksen K, Bjorkstrand B, Simons-
son B, Oberg G, Ljungman P. Tetanus immunity in
autologous bone marrow and blood stem cell transplant
recipients. Bone Marrow Transplant 1998; 22:67-71;
PMID:9678798; http://dx.doi.org/10.1038/sj.
bmt.1701289
47. Torres HA, Davila M. Reactivation of hepatitis B virus
and hepatitis C virus in patients with cancer. Nat Rev
Clin Oncol 2012; 9:156-66; PMID:22271089; http://
dx.doi.org/10.1038/nrclinonc.2012.1
48. Lok AS, Liang RH, Chiu EK, Wong KL, Chan TK,
Todd D. Reactivation of hepatitis B virus replication in
patients receiving cytotoxic therapy. Report of a pro-
spective study. Gastroenterology 1991; 100:182-8;
PMID:1983820
49. Yeo W, Chan PK, Zhong S, Ho WM, Steinberg JL,
Tam JS, Hui P, Leung NW, Zee B, Johnson PJ. Fre-
quency of hepatitis B virus reactivation in cancer
patients undergoing cytotoxic chemotherapy: a prospec-
tive study of 626 patients with identification of risk fac-
tors. J Med Virol 2000; 62:299-307; PMID:11055239;
http://dx.doi.org/10.1002/1096-9071(200011)
62:3%3c299::AID-JMV1%3e3.0.CO;2-0
50. Zignol M, Peracchi M, Tridello G, Pillon M, Fregonese
F, DElia R, Zanesco L, Cesaro S. Assessment of humoral
immunity to poliomyelitis, tetanus, hepatitis B, measles,
rubella, and mumps in children after chemotherapy. Can-
cer 2004; 101:635-41; PMID:15274078; http://dx.doi.
org/10.1002/cncr.20384
51. Idilman R, Arat M. Evaluation and management of
hepatitis B virus infection in hematopoietic stem cell
Human Vaccines & Immunotherapeutics
transplantation: before and after transplantation. Exp
Rev Anti-Infect Ther 2011; 9:641-52;
PMID:21819330; http://dx.doi.org/10.1586/eri.11.79
52. Weitberg AB, Weitzman SA, Watkins E, Hinkle C,
ORourke S, Dienstag JL. Immunogenicity of hepatitis
B vaccine in oncology patients receiving chemotherapy.
J Clin Oncol 1985; 3:718-22; PMID:3158725
53. Centers for Disease C, Prevention. Recommendation of
the advisory committee on immunization practices
(ACIP) for use of quadrivalent meningococcal conju-
gate vaccine (MenACWY-D) among children aged 9
through 23 months at increased risk for invasive menin-
gococcal disease. MMWR Morb Mort Wkly Rep 2011;
60:1391-2; PMID:21993344
54. Coleman CN, McDougall IR, Dailey MO, Ager P,
Bush S, Kaplan HS. Functional hyposplenia after
splenic irradiation for Hodgkins disease. Ann Intern
Med 1982; 96:44-7; PMID:7053701; http://dx.doi.
org/10.7326/0003-4819-96-1-44
55. Yu JW, Borkowski A, Danzig L, Reiter S, Kavan P,
Mazer BD. Immune response to conjugated meningo-
coccal C vaccine in pediatric oncology patients. Pediatr
Blood Cancer 2007; 49:918-23; PMID:17366523;
http://dx.doi.org/10.1002/pbc.21174
56. Markowitz LE, Dunne EF, Saraiya M, Chesson HW, Cur-
tis CR, Gee J, Bocchini JA Jr, Unger ER; Centers for Dis-
ease Control and Prevention (CDC). Human
papillomavirus vaccination: recommendations of the advi-
sory committee on immunization practices (ACIP).
MMWR Recomm Rep 2014; 63:1-30; PMID:25167164
57. Levin MJ, Moscicki AB, Song LY, Fenton T, Meyer
WA, 3rd, Read JS, Handelsman EL, Nowak B, Sattler
CA, Saah A, et al. Safety and immunogenicity of a
quadrivalent human papillomavirus (types 6, 11, 16,
and 18) vaccine in HIV-infected children 7 to 12 years
old. J Acquir Immune Defici Syndr 2010; 55:197-204;
PMID:20574412; http://dx.doi.org/10.1097/QAI.
0b013e3181de8d26
58. Gardner P, Eickhoff T, Poland GA, Gross P, Griffin
M, LaForce FM, Schaffner W, Strikas R. Adult immu-
nizations. Ann Intern Med 1996; 124:35-40;
PMID:7503476; http://dx.doi.org/10.7326/0003-
4819-124-1_Part_1-199601010-00007
59. Mutsch M, Spicher VM, Gut C, Steffen R. Hepatitis A
virus infections in travelers, 1988-2004. Clin Infect Dis
2006; 42:490-7; PMID:16421793; http://dx.doi.org/
10.1086/499816
60. Gunther M, Stark K, Neuhaus R, Reinke P, Schroder
K, Bienzle U. Rapid decline of antibodies after hepatitis
A immunization in liver and renal transplant recipients.
Transplantation 2001; 71:477-9; PMID:11233913;
http://dx.doi.org/10.1097/00007890-200102150-
00023
61. Morales-Castillo ME, Alvarez-Munoz MT, Solorzano-
Santos F, Gonzalez-Robledo R, Jasso-Gutierrez L,
Munoz-Hernandez O. Live varicella vaccine in both
immunocompromised and healthy children. Arch Med
Res 2000; 31:85-7; PMID:10767486; http://dx.doi.
org/10.1016/S0188-4409(99)00080-6
62. Leung TF, Li CK, Hung EC, Chan PK, Mo CW,
Wong RP, Chik KW. Immunogenicity of a two-
dose regime of varicella vaccine in children with
cancers. Eur J Haematol 2004; 72:353-7;
PMID:15059071; http://dx.doi.org/10.1111/j.1600-
0609.2004.00216.x
63. Caniza MA, Hunger SP, Schrauder A, Valsecchi MG,
Pui CH, Masera G, Members of International Study
Group of Childhood ALL ( Ponte di Legno Working
Group). The controversy of varicella vaccination in
children with acute lymphoblastic leukemia. Pediatr
Blood Cancer 2012; 58:12-6; PMID:20848637;
http://dx.doi.org/10.1002/pbc.22759
64. Bhalla P, Forrest GN, Gershon M, Zhou Y, Chen J,
LaRussa P, Steinberg S, Gershon AA. Disseminated,
persistent, and fatal infection due to the vaccine strain
of varicella-zoster virus in an adult following stem cell
transplantation. Clin Infect Dis 2015; 60:1068-74;
PMID:25452596
2613
65. Tseng HF, Tartof S, Harpaz R, Luo Y, Sy LS, Hetcher
RC, Jacobsen SJ. Vaccination against zoster remains effec-
tive in older adults who later undergo chemotherapy.
Clin Infect Dis 2014; 59:913-9; PMID:25097079;
http://dx.doi.org/10.1093/cid/ciu498
66. Harpaz R, Ortega-Sanchez IR, Seward JF, Advi-
sory Committee on Immunization Practices Cen-
ters for Disease C, Prevention. Prevention of
herpes zoster: recommendations of the advisory
committee on immunization practices (ACIP).
MMWR Recomm Rep 2008; 57:1-30; quiz CE2-
4; PMID:18528318
67. Kernahan J, McQuillin J, Craft AW. Measles in chil-
dren who have malignant disease. Br Med J 1987;
295:15-8; PMID:3113596; http://dx.doi.org/10.1136/
bmj.295.6589.15
68. Mustafa MM, Weitman SD, Winick NJ, Bellini WJ,
Timmons CF, Siegel JD. Subacute measles encephalitis
in the young immunocompromised host: report of two
cases diagnosed by polymerase chain reaction and
treated with ribavirin and review of the literature. Clin
Infect Dis 1993; 16:654-60; PMID:8323578; http://
dx.doi.org/10.1093/clind/16.5.654
69. Gray MM, Hann IM, Glass S, Eden OB, Jones PM,
Stevens RF. Mortality and morbidity caused by measles
in children with malignant disease attending four major
treatment centres: a retrospective review. Br Med J
1987; 295:19-22; PMID:3113597; http://dx.doi.org/
10.1136/bmj.295.6589.19
70. Feldman S, Andrew M, Norris M, McIntyre B, Iyer R.
Decline in rates of seropositivity for measles, mumps,
and rubella antibodies among previously immunized
children treated for acute leukemia. Clin Infect Dis
1998; 27:388-90; PMID:9709893; http://dx.doi.org/
10.1086/514661
71. McCarthy M. Measles cases exceed 100 in US out-
break. Bmj 2015; 350:h622; PMID:25646696; http://
dx.doi.org/10.1136/bmj.h622
72. Patel SR, Ortin M, Cohen BJ, Borrow R, Irving D,
Sheldon J, Heath PT. Revaccination of children after
completion of standard chemotherapy for acute leuke-
mia. Clin Infect Dis 2007; 44:635-42;
PMID:17278052; http://dx.doi.org/10.1086/511636
73. Di Sabatino A, Carsetti R, Corazza GR. Post-splenec-
tomy and hyposplenic states. Lancet 2011; 378:86-97;
2614
PMID:21474172; http://dx.doi.org/10.1016/S0140-
6736(10)61493-6
74. Edgren G, Almqvist R, Hartman M, Utter GH. Sple-
nectomy and the risk of sepsis: a population-based
cohort study. Ann Surg 2014; 260:1081-7;
PMID:24374533; http://dx.doi.org/10.1097/
SLA.0000000000000439
75. Kuchar E, Nitsch-Osuch A, Stolarczyk C, Kurpas D,
Zycinska K, Wardyn K, Szenborn L. Immunization
coverage against capsular bacteria in splenectomized
patients. Adv Exp Med Biol 2013; 788:139-45;
PMID:23835971; http://dx.doi.org/10.1007/978-94-
007-6627-3_21
76. Rosado MM, Gesualdo F, Marcellini V, Di Sabatino A,
Corazza GR, Smacchia MP, Nobili B, Baronci C,
Russo L, Rossi F, et al. Preserved antibody levels and
loss of memory B cells against pneumococcus and teta-
nus after splenectomy: tailoring better vaccination strat-
egies. Eur J Immunol 2013; 43:2659-70;
PMID:23813052; http://dx.doi.org/10.1002/eji.
201343577
77. Kim DK, Bridges CB, Harriman KH, Advisory Com-
mittee on Immunization P. Advisory committee on
immunization practices recommended immunization
schedule for adults aged 19 years or older: United
States, 2015*. Ann Intern Med 2015; 162:214-23;
http://dx.doi.org/10.7326/M14-2755
78. Balmer P, Falconer M, McDonald P, Andrews N,
Fuller E, Riley C, Kaczmarski E, Borrow R. Immune
response to meningococcal serogroup C conjugate vac-
cine in asplenic individuals. Infect Immun 2004;
72:332-7; PMID:14688112; http://dx.doi.org/
10.1128/IAI.72.1.332-337.2004
79. Cohn AC, MacNeil JR, Clark TA, Ortega-Sanchez IR,
Briere EZ, Meissner HC, Baker CJ, Messonnier NE;
Centers for Disease Control and Prevention (CDC).
Prevention and control of meningococcal disease: rec-
ommendations of the advisory committee on immuni-
zation practices (ACIP). MMWR Recomm Rep 2013;
62:1-28; PMID:23515099
80. Snape MD, Perrett KP, Ford KJ, John TM, Pace
D, Yu LM, Langley JM, McNeil S, Dull PM, Ced-
dia F, et al. Immunogenicity of a tetravalent menin-
gococcal glycoconjugate vaccine in infants: a
randomized controlled trial. Jama 2008; 299:173-
Human Vaccines & Immunotherapeutics
84; PMID:18182599; http://dx.doi.org/10.1001/
jama.2007.29-c
81. Borrow R, Joseph H, Andrews N, Acuna M, Long-
worth E, Martin S, Peake N, Rahim R, Richmond P,
Kaczmarski E, et al. Reduced antibody response to
revaccination with meningococcal serogroup A polysac-
charide vaccine in adults. Vaccine 2000; 19:1129-32;
PMID:11137248; http://dx.doi.org/10.1016/S0264-
410X(00)00317-0
82. Kristensen K. Antibody response to a Haemophilus
influenzae type b polysaccharide tetanus toxoid conju-
gate vaccine in splenectomized children and adoles-
cents. Scand J Infect Dis 1992; 24:629-32;
PMID:1465581; http://dx.doi.org/10.3109/
00365549209054649
83. Cimaz R, Mensi C, DAngelo E, Fantola E, Milone V,
Biasio LR, Carnelli V, Zanetti AR. Safety and immuno-
genicity of a conjugate vaccine against Haemophilus
influenzae type b in splenectomized and nonsplenec-
tomized patients with Cooley anemia. J Infect Dis
2001; 183:1819-21; PMID:11372038; http://dx.doi.
org/10.1086/320727
84. Askling HH, Dalm VA. The medically immunocom-
promised adult traveler and pre-travel counseling: status
quo 2014. Travel Med Infect Dis 2014; 12:219-28;
PMID:24821082; http://dx.doi.org/10.1016/j.tmaid.
2014.04.009
85. Kotton CN. Travel and transplantation: travel-related
diseases in transplant recipients. Curr Opin Organ
Transplant 2012; 17:594-600; PMID:23147910
86. Yee SS, Dutta PR, Solin LJ, Vapiwala N, Kao GD.
Lack of compliance with national vaccination guide-
lines in oncology patients receiving radiation therapy. J
Support Oncol 2010; 8:28-34; PMID:20235421;
http://dx.doi.org/10.1016/j.suponc.2010.10.005
87. Adriani KS, Brouwer MC, van der Ende A, van de Beek
D. Bacterial meningitis in adults after splenectomy and
hyposplenic states. Mayo Clin Proc 2013; 88:571-8;
PMID:23628588; http://dx.doi.org/10.1016/j.
mayocp.2013.02.009
88. Lammers AJ, Veninga D, Lombarts MJ, Hoekstra JB,
Speelman P. Management of post-splenectomy patients
in the Netherlands. Eur J Clin Microbiol Infect Dis
2010; 29:399-405; PMID:20094896; http://dx.doi.
org/10.1007/s10096-009-0870-x
Volume 11 Issue 11