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Immunizations in adults with cancer

Patricia L Hibberd, MD, PhD
Section Editor
Michael Boeckh, MD
Deputy Editor
Anna R Thorner, MD


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 "Prevention of seasonal influenza with antiviral drugs in adults" and "Seasonal influenza in children: Prevention and treatment with antiviral drugs".)

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 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: Overview".)


Adults 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, immunotherapy, and/or radiotherapy that is administered. 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 they should not be given during periods of immunosuppression from chemotherapy immunotherapy 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.)

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Literature review current through: Nov 2017. | This topic last updated: Aug 02, 2017.
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  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 AT, Duchin J, Vázquez M. 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 July 07, 2017).
  4. Hamarström V, Pauksen K, Svensson H, et al. Tetanus immunity in patients with hematological malignancies. Support Care Cancer 1998; 6:469.
  5. van der Does-van den Berg A, Hermans J, Nagel J, van Steenis G. Immunity to diphtheria, pertussis, tetanus, and poliomyelitis in children with acute lymphocytic leukemia after cessation of chemotherapy. Pediatrics 1981; 67:222.
  6. 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.
  7. Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2012; 61:816.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. Ammann AJ, Schiffman G, Addiego JE, et al. Immunization of immunosuppressed patients with pneumococcal polysaccharide vaccine. Rev Infect Dis 1981; 3 Suppl:S160.
  13. Siber GR, Schur PH, Aisenberg AC, et al. Correlation between serum IgG-2 concentrations and the antibody response to bacterial polysaccharide antigens. N Engl J Med 1980; 303:178.
  14. Feldman S, Malone W, Wilbur R, Schiffman G. Pneumococcal vaccination in children with acute lymphocytic leukemia. Med Pediatr Oncol 1985; 13:69.
  15. 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.
  16. French N, Gordon SB, Mwalukomo T, et al. A trial of a 7-valent pneumococcal conjugate vaccine in HIV-infected adults. N Engl J Med 2010; 362:812.
  17. Advisory Committee on Immunization Practices. Summary Report, February 22-23, 2012. http://www.cdc.gov/vaccines/recs/acip/downloads/min-feb12.pdf (Accessed on June 25, 2012).
  18. Cohn AC, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62:1.
  19. Centers for Disease Control and Prevention (CDC). Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices--United States, 2013-2014. MMWR Recomm Rep 2013; 62:1.
  20. 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.
  21. Gribabis DA, Panayiotidis P, Boussiotis VA, et al. Influenza virus vaccine in B-cell chronic lymphocytic leukaemia patients. Acta Haematol 1994; 91:115.
  22. Anderson H, Petrie K, Berrisford C, et al. Seroconversion after influenza vaccination in patients with lung cancer. Br J Cancer 1999; 80:219.
  23. Brydak LB, Całbecka M. Immunogenicity of influenza vaccine in patients with hemato-oncological disorders. Leuk Lymphoma 1999; 32:369.
  24. 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.
  25. 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.
  26. 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.
  27. 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.
  28. Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007; 56:1.
  29. Mast EE, Weinbaum CM, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep 2006; 55:1.
  30. Kaplan LJ, Daum RS, Smaron M, McCarthy CA. Severe measles in immunocompromised patients. JAMA 1992; 267:1237.
  31. 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.
  32. 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.
  33. 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.
  34. Bhalla P, Forrest GN, Gershon M, et al. 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.
  35. Rusthoven JJ, Ahlgren P, Elhakim T, et al. Varicella-zoster infection in adult cancer patients. A population study. Arch Intern Med 1988; 148:1561.
  36. Wilson JF, Marsa GW, Johnson RE. Herpes zoster in Hodgkin's disease. Clinical, histologic, and immunologic correlations. Cancer 1972; 29:461.
  37. 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.
  38. 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.