IMMUNIZATIONS IN IMMUNOSUPPRESSED PTS

Recommendations for vaccination of cancer pts receiving chemotherapy, pts with Hodgkin’s disease, and hematopoietic stem cell transplant recipients are listed in Table 82-3. In solid organ transplant recipients, the usual vaccines and boosters should be given before immunosuppression. Pts with continued immunosuppression should have pneumococcal vaccination repeated every 5 years and should generally not receive live vaccines.

TABLE 82-3: Vaccination of Cancer and Transplant Pts Receiving Chemotherapy^a
VACCINE	USE IN INDICATED PTS
VACCINE	INTENSIVE CHEMOTHERAPY	HODGKIN’S DISEASE	HEMATOPOIETIC STEM CELL TRANSPLANTATION	SOLID ORGAN TRANSPLANTATION
Diphtheria-tetanus^b	Primary series and boosters as necessary	No special recommendation	Three doses given 6–12 months after transplantation	Administer TDaP before transplantation.
Poliomyelitis^c	Complete primary series and boosters	No special recommendation	Three doses given 6–12 months after transplantation	Administer before transplantation.
Haemophilus influenzae type b conjugate	Primary series and booster for children	Single dose for adults	Three doses given 6–12 months after transplantation (separated by 1 month)	Administer before transplantation.
Human papillomavirus^d	A 9-valent vaccine is approved for males and females 9–45 years of age.	A 9-valent vaccine is approved for males and females 9–45 years of age.	A 9-valent vaccine is approved for males and females 9–45 years of age.	A 9-valent vaccine is approved for males and females 9–45 years of age.
Hepatitis A	As indicated for normal hosts on the basis of occupation and lifestyle	As indicated for normal hosts on the basis of occupation and lifestyle	As indicated for normal hosts on the basis of occupation and lifestyle	Administer before transplantation.
Hepatitis B	Same as for normal hosts	As indicated for normal hosts on the basis of occupation and lifestyle	Three doses given 6–12 months after transplantation	Administer before transplantation.
Pneumococcal conjugate, pneumococcal polysaccharide^e	Finish series prior to chemotherapy if possible	Pts with splenectomy should receive PPSV23.	Three doses of PCV13, beginning 3–6 months after transplantation, are followed by a dose of PPSV23 at least 8 weeks later. A second PPSV23 dose can be given 5 years later.	Administer in 2 steps.^f
Quadrivalent meningococcal vaccine^g	Should be administered to splenectomized pts and to pts living in endemic areas, including college students in dormitories	Should be administered to splenectomized pts and to pts living in endemic areas, including college students in dormitories. An additional dose can be given after 5 years.	Should be administered to splenectomized pts and to pts living in endemic areas, including college students in dormitories. An additional dose can be given after 5 years.	Administer before transplantation.
Influenza	Seasonal immunization	Seasonal immunization	Seasonal immunization (A seasonal dose is recommended and can be given as early as 4 months after transplantation; if given <6 months after transplantation, an additional dose is recommended.)	Seasonal immunization
Measles/mumps/rubella	Contraindicated	Contraindicated during chemotherapy	After 24 months in pts without graft-versus-host disease	Administer before transplantation.
Varicella-zoster virus^h	Contraindicatedⁱ	Contraindicated	Contraindicated (CDC recommends use on a case-by-case basis following reevaluation.)	Administer before transplantation.

^aThe latest recommendations by the Advisory Committee on Immunization Practices and the CDC guidelines can be found at http://www.cdc.gov/vaccines.

^bA single dose of tetanus–diphtheria–acellular pertussis (TDaP), followed by a booster dose of tetanus-diphtheria (Td) every 10 years, is recommended for adults.

^cLive-virus vaccine is contraindicated; inactivated vaccine should be used.

^dCheck the CDC website (www.cdc.gov/vaccines) for updated recommendations.

^eTwo types of vaccine are used to prevent pneumococcal disease. A conjugate vaccine active against 13 serotypes (13-valent pneumococcal conjugate vaccine, or PCV13) is currently administered in three separate doses to all children. A polysaccharide vaccine active against 23 serotypes (23-valent pneumococcal polysaccharide vaccine, or PPSV23) elicits titers of antibody lower than those achieved with the conjugate vaccine, and immunity may wane more rapidly. Because the ablative chemotherapy given to recipients of hematopoietic stem cell transplants eradicates immunologic memory, revaccination is recommended for all such pts. Vaccination is much more effective once immunologic reconstitution has occurred; however, because of the need to prevent serious disease, pneumococcal vaccine should be administered 6–12 months after transplantation in most cases. Because PPSV23 includes serotypes not present in PCV13, recipients of stem cell transplants should receive a dose of PPSV23 at least 8 weeks after the last dose of PCV13. Although antibody titers from PPSV23 clearly decay, experience with multiple doses of PPSV23 is limited, as are data on the safety, toxicity, or efficacy of such a regimen. For this reason, the CDC currently recommends the administration of one additional dose of PPSV23 at least 5 years after the last dose to immunocompromised pts, including transplant recipients, as well as pts with Hodgkin’s disease, multiple myeloma, lymphoma, or generalized malignancies. Beyond this single additional dose, further doses are not recommended at this time.

^fStep 1: Administer one dose of the pneumococcal conjugate vaccine Prevnar^® (13-valent pneumococcal vaccine, PCV13) to all transplant candidates. If a candidate has previously been vaccinated with Pneumovax^® (23-valent pneumococcal vaccine, PPSV23), at least 6 months should have elapsed before Prevnar is administered. Step 2: Administer one dose of Pneumovax at least 8 weeks after vaccination with PCV13; follow with a booster dose of Pneumovax 5 years later. If the pt has previously been vaccinated with Pneumovax (i.e., before receiving Prevnar), at least 3 years should have elapsed before the second dose of Pneumovax is administered.

^gMeningococcal conjugate vaccine MenACWY is recommended for adults ≤55 years old, and meningococcal polysaccharide vaccine (MPSV4) is recommended for those ≥56 years old.

^hIncludes both varicella vaccine for children and zoster vaccine for adults.

ⁱContact the manufacturer for more information on use in children with acute lymphocytic leukemia.

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