Immunizations in patients with cancer
- Patricia L Hibberd, MD, PhD
Patricia L Hibberd, MD, PhD
- Chair, Department of Global Health
- Boston University School of Public Health
- Section Editors
- Michael Boeckh, MD
Michael Boeckh, MD
- Section Editor — Compromised Host Infections
- Professor of Medicine
- University of Washington
- David G Poplack, MD
David G Poplack, MD
- Section Editor — Pediatric Oncology
- Professor of Pediatrics
- Baylor College of Medicine
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. 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 "Prevention of seasonal influenza with antiviral drugs in adults" and "Seasonal influenza in children: Prevention and treatment with antiviral drugs".)
The rationale for immunizing patients 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 HIV as well as in healthy children and adults are discussed separately. (See "Immunizations in hematopoietic cell transplant candidates and recipients" and "Immunizations in solid organ transplant candidates and recipients" and "Immunizations in HIV-infected patients" and "Approach to immunizations in healthy adults" and "Standard immunizations for children and adolescents".)
Patients with cancer are at variable risk of morbidity and mortality from the infections that can usually be prevented by immunization, depending upon the underlying disease and the type of cancer chemotherapy and radiotherapy that is administered. Patients with hematologic malignancies tend to be more compromised 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).
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) (table 1) . The United States Advisory Committee on Immunization Practices (ACIP) also includes recommendations for immunocompromised patients in their guidelines (figure 1).
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- GENERAL APPROACH
- Timing of immunizations
- INACTIVATED VACCINES
- Tetanus toxoid, diphtheria toxoid, and pertussis vaccines
- Polio vaccine
- Pneumococcal vaccine
- Haemophilus influenzae vaccine
- Meningococcal vaccine
- Influenza vaccine
- Human papilloma virus vaccine
- Hepatitis B vaccine
- Hepatitis A vaccine
- LIVE VIRUS VACCINES
- Measles, mumps, and rubella vaccines
- Varicella vaccine
- Zoster vaccine
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS