VACCINATION IN CHILDHOOD MALIGNANCY

1. VACCINATION IN CHILDHOOD MALIGNANCY Prof. Mervat A Hesham 2010

2. To Vaccinate or Not To Vaccinate? • All vaccination decisions should be based on the benefit from vaccine (immunity) versus the risk from the vaccine (adverse reaction) • Risk depends on characteristics of the vaccine and recipient

3. Ultimate goal:eradication of disease Immediate goal:prevention of disease TYPES OF PROTECTION INDUCED: • Complete protection for life • Partial protection (booster doses)

4. GOALS CAN BE ACHIEVED IN 2 WAYS: • ACTIVE immunization • PASSIVE immunization

5. Immunity ActivePassive Injection of an Antigen Injection of preformed Toxoid, Live Attenuated Viral, antibiotics (gammaglobulins) Killed Bacterial Vaccine Protection produced by the Protection transferred from person’s own immune another person or animal System Usually permanent Temporary protection that wanes with time

6. ACTIVE IMMUNIZATION - Live attenuated viral vaccine – Measles, MMR, OPV, Varicella - Inactivated viral vaccine – Influenza , Hep A, IPV, Hep B (recombinant DNA) - Detoxified exotoxin (Toxoid) – Diphtheria, Tetanus - Purified protein antigens – acellular Pertussis, Hep B - Whole cell pertussis vaccine – DTP - Inactivated acellular pertussis vaccine – DTaP - Capsular polysaccharide – Typhoid - Protein conjugated polysaccharide vaccine – Hib, Pneumococcal - Live attenuated bacterial vaccine – BCG (Bacille Calmette Guerin)

8. Classification of Vaccines • Live • MMR • Varicella/zoster • Rotavirus • Yellow fever • Oral typhoid • Smallpox (vaccinia) • BCG • Inactivated • All others

9. Contraindication and Precautions • Contraindication • a condition in a recipient that greatly increases the chance of a serious adverse reaction • Precaution • a condition in a recipient that might increase the chance or severity of an adverse reaction, or • might compromise the ability of the vaccine to produce immunity

10. ACTIVE IMMUNIZATION - Generalities • Contraindications to ALL VACCINES: - serious allergic reaction (anaphylaxis) after a previous vaccine dose - serious allergic reaction to a vaccine component - encephalopathy not due to another identifiable cause occurring within 7 days of pertussis vaccination • Precautions : - moderate or severe acute illness with or without fever

11. ACTIVE IMMUNIZATION - Generalities Contraindications to ALL LIVE VACCINES: • immunocompromised patients • patients given immunoglobulin and blood products for the past 3 months • pregnancy and possibility of getting pregnant within 3 months • household contacts of immunocompromised patients* (OPV)

12. Contraindications and Precautions Condition Allergy to component Encephalopathy Immunosuppression Severe illness Recent blood product Live C --- C P P** Inactivated C C V P V C=contraindication P=precaution V=vaccinate if indicated **MMR and varicella-containing (except zoster vaccine) only

13. Immunosuppression • Disease • Congenital immunodeficiency • Leukemia or lymphoma • Generalized malignancy • Chemotherapy • Alkylating agents • Antimetabolites • Radiation • Corticosteroids • Immunomodulators?

14. The Spectrum of Altered Immunocompetence Do not vaccinate* or poor response Vaccinate No or little suppression Severe suppression Chemotherapy Immunomodulators High dose steroids Post-transplant Rx Low dose steroids BM ablation Intermittant/LD chemo Asplenia Autoimmune diseases * Live vaccines

15. Immunosuppression inmalignancy • Oncology patients receiving chemotherapy should be regarded as immunosuppressed during and for 3 months post chemotherapy. • Allogeneic HSCT patients not on immunosuppressive therapy should still be regarded as immunosuppressed for 2 years post transplant. • Autologous HSCT patients are regarded as immunosuppressed for 1 year post transplant

16. Guidelines of vaccination inmalignancy •Live attenuated vaccines must be avoided, i.e oral polio, BCG, MMR (Measles, Mumps, Rubella), Varicella. • Killed vaccines may be given as per schedule to immunosuppressed children without extra risk but may not be effective. Killed vaccines are best given when the Absolute Neutrophil Count (ANC) and Absolute Lymphocyte Count (ALC) are >1.0 x 109/L. • Influenza vaccine should be given on an annual basis to children >6 months of age when ALC >1.0 x 109/L.

17. •Acute lymphoblastic leukemia patients: It is best to wait until they reach the maintenance phase of chemotherapy and give scheduled immunization prior to steroid pulse. •Passive Immunization for exposed patients: •Hepatitis A Immunoglobulin 0.02 mL/kg IM (max dose 2 mL) •Hepatitis B HBIG 0.06 mL/kg IM (max dose 5 mL) in previously unvaccinated patients •Measles Immunoglobulin 0.5 mL/kg IM (max dose 15 mL); give within 6 days of exposure regardless of previous immunization status •VaricellaVZIG 1 vial/10 kg IM (max 5 vials); give within 48 hours of exposure in susceptible individuals

18. Household Members of Immunosuppressed Individuals • Oral poliovaccine is the only live attenuated vaccine which should NOT be given to household members of an immunosuppressed child as the virus is shed for up to 12 weeks post immunization. • parents , siblingsand household members should receive all currently recommended vaccines to reduce the risk of exposure of the immunosuppressed patient. These include: ~ Varicella vaccine for anyone with a negative history of varicella zoster virus (VZV) infection ~ Influenza vaccine on an annual basis ~ Meningococcal C conjugate vaccine ~ Pneumococcal conjugate vaccine

19. Post Treatment Patients • For all patients except allogeneic transplants, active immunization should be continued. Many patients will have diminished titres. We recommend evaluating the immunity status six months after completing all chemotherapy. Measure antibody titres for polio, tetanus, measles, mumps, rubella, HSV, VZV, Hepatitis B. Boosters including live vaccines to be given depending on immune status.

20. Post Treatment Patients • Allogeneic HSCT patients should still be regarded as immunosuppressed for two years post transplant. A complete re-immunization with exception of no live viruses should be started • Live vaccines should not be given until two years post treatment.

21. Revaccination • Immunity to vaccine-preventable diseases established prior to immunosuppression is not lost because of the munosuppression* • Routine revaccination following immunosuppression is not necessary except for vaccines received during immunosuppression *except HSCT recipients

22. Guidelines of MMR and varicella vaccines • Leukemia, lymphoma or generalized malignancy: •  MMR and varicella vaccines are contraindicated until ≥ 3 months has elapsed since the client was cured and immunosuppressive therapy was discontinued. • Acute lymphocytic leukemia (ALL) – varicella vaccine is recommended if: 1- the client’s disease has been in remission for ≥ 12 months, 2- the client’s total lymphocyte count is ≥ 1.2 X 109/L, 3-the client is not receiving radiation therapy, 4- maintenance chemotherapy can be withheld for at least 1 week before to1 week after immunization.

23. Guidelines of MMR and varicella vaccines • Solid organ transplant candidate or recipient: • MMR and varicella vaccines are recommended for solid organ transplant candidates. • MMR and varicella vaccines are contraindicated for solid organ transplant recipients. • Hematopoietic stem cell transplant (HSCT): • MMR and varicella vaccines may be considered if the client is ≥ 2 years post transplant AND there is no graft versus host disease and no munosuppressive treatment.

24. Guidelines of MMR and varicella vaccines • High doses of oral corticosteroid therapy of more than 14 days duration(more than 2 mg/kg or >20 mg of prednisone daily): •  MMR and varicella vaccines may be considered if the client is able to discontinue therapy for one month prior to immunization. •  It is not necessary to obtain a written referral for immunization of clients who are receiving physiologic replacement of corticosteroids (<2mg/kg of prednisone per day) or who are receiving oral corticosteroid therapy for 14 days or less.

25. Guidelines of MMR and varicella vaccines • Immunosuppressive therapy(e.g., chemotherapy, radiation therapy, and certain anti-rheumatic drugs): • Live vaccines are contraindicated during therapy but may be considered if only low doses of immunosuppressive drugs are required and there is significant risk of wild-type infection. • MMR and varicella vaccines may be considered if ≥ 3 months has elapsed since immunosuppressive therapy was discontinued.

26. SPACING OF VACCINES AND ANTIBODY-CONTAINING PRODUCTS • After immunization with live attenuated virus vaccine (i.e., MMR or varicella vaccine), vaccine virus replication and stimulation of immunity occur in about 1 - 2 weeks. • If the Ig preparation of blood product is given >14 days after MMR or varicella vaccine, the immunization does not have to be repeated. • If Ig or a blood product is administered <14 days post immunization with MMR or varicella vaccine, immunization should be repeated

27. SPACING OF VACCINES AND BLOOD DONATION

31. conclusion • As a general rule, It is preferable to vaccinate* an immunocompromised person and obtain a less-than-optimal response than to withhold the vaccine and obtain NO response • Persons vaccinated during immuno-suppressive therapy or radiation should be revaccinated. *inactivated vaccines only • immunization with killed vaccines can be resumed 6 months after the completion of chemotherapy, and live vaccines may be administered 12 months afterthe completion ofchemotherapy.

32. THANK YOU