IMMUNIZATIONS IN IMMUNOSUPPRESSED PTS

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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 Chemotherapya
VACCINEUSE IN INDICATED PTS
INTENSIVE CHEMOTHERAPYHODGKIN’S DISEASEHEMATOPOIETIC STEM CELL TRANSPLANTATIONSOLID ORGAN TRANSPLANTATION
Diphtheria-tetanusbPrimary series and boosters as necessaryNo special recommendationThree doses given 6–12 months after transplantationAdminister TDaP before transplantation.
PoliomyelitiscComplete primary series and boostersNo special recommendationThree doses given 6–12 months after transplantationAdminister before transplantation.
Haemophilus influenzae type b conjugatePrimary series and booster for childrenSingle dose for adultsThree doses given 6–12 months after transplantation (separated by 1 month)Administer before transplantation.
Human papillomavirusdA 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 AAs indicated for normal hosts on the basis of occupation and lifestyleAs indicated for normal hosts on the basis of occupation and lifestyleAs indicated for normal hosts on the basis of occupation and lifestyleAdminister before transplantation.
Hepatitis BSame as for normal hostsAs indicated for normal hosts on the basis of occupation and lifestyleThree doses given 6–12 months after transplantationAdminister before transplantation.
Pneumococcal conjugate, pneumococcal polysaccharideeFinish series prior to chemotherapy if possiblePts 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 vaccinegShould be administered to splenectomized pts and to pts living in endemic areas, including college students in dormitoriesShould 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.
InfluenzaSeasonal immunizationSeasonal immunizationSeasonal 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/rubellaContraindicatedContraindicated during chemotherapyAfter 24 months in pts without graft-versus-host diseaseAdminister before transplantation.
Varicella-zoster virushContraindicatediContraindicatedContraindicated (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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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 Chemotherapya
VACCINEUSE IN INDICATED PTS
INTENSIVE CHEMOTHERAPYHODGKIN’S DISEASEHEMATOPOIETIC STEM CELL TRANSPLANTATIONSOLID ORGAN TRANSPLANTATION
Diphtheria-tetanusbPrimary series and boosters as necessaryNo special recommendationThree doses given 6–12 months after transplantationAdminister TDaP before transplantation.
PoliomyelitiscComplete primary series and boostersNo special recommendationThree doses given 6–12 months after transplantationAdminister before transplantation.
Haemophilus influenzae type b conjugatePrimary series and booster for childrenSingle dose for adultsThree doses given 6–12 months after transplantation (separated by 1 month)Administer before transplantation.
Human papillomavirusdA 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 AAs indicated for normal hosts on the basis of occupation and lifestyleAs indicated for normal hosts on the basis of occupation and lifestyleAs indicated for normal hosts on the basis of occupation and lifestyleAdminister before transplantation.
Hepatitis BSame as for normal hostsAs indicated for normal hosts on the basis of occupation and lifestyleThree doses given 6–12 months after transplantationAdminister before transplantation.
Pneumococcal conjugate, pneumococcal polysaccharideeFinish series prior to chemotherapy if possiblePts 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 vaccinegShould be administered to splenectomized pts and to pts living in endemic areas, including college students in dormitoriesShould 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.
InfluenzaSeasonal immunizationSeasonal immunizationSeasonal 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/rubellaContraindicatedContraindicated during chemotherapyAfter 24 months in pts without graft-versus-host diseaseAdminister before transplantation.
Varicella-zoster virushContraindicatediContraindicatedContraindicated (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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