Vaccination of immunocompromised patients

Abstract

Clin Microbiol Infect 2012; 18 (Suppl. 5): 93–99 Abstract Vaccination of immunocompromised patients is challenging both regarding efficacy and safety. True efficacy data are lacking so existing recommendations are based on immune responses and safety data. Inactivated vaccines can generally be used without risk but the patients who are most at risk for infectious morbidity and mortality as a result of their severely immunosuppressed state are also those least likely to respond to vaccination. However, vaccination against pneumococci, Haemophilus influenzae and influenza are generally recommended. Live vaccines must be used with care because the risk for vaccine‐associated disease exists.

CD4 T Cell Help Is Limiting and Selective during the Primary B Cell Response to Influenza Virus Infection

“…By generating no B cell memory, the breadth of future responses will not be restricted by a preexisting B cell repertoire. This type of advantage would be directly applicable to situations where responses to vaccination are already suboptimal, as in the elderly or immunocompromised (64)(65)(66)(67)(68). Through provision of a selective boost to the CD4 T cell repertoire, intrinsic antibody interference and shifts in the specificity of the memory B cell repertoire can be bypassed.…”

Practical review of immunizations in adult patients with cancer

“…33 In the case of patients after stem cell transplant, the recommendation is to use repeated doses of the pneumococcus-conjugated vaccine to maintain durable responses. 6 Repeated doses of PPSV23 administered at intervals of less than 5 years result in lower antibody levels in the general population; this phenomenon is known as hypo-responsiveness and is caused by the depletion of polysaccharide-specific B cells. 41 Earlier randomized studies of pneumococcal vaccination had been underpowered to evaluate the efficacy against communityacquired pneumonia secondary to the vaccine strains; 34 however a recent multicenter study including almost 85,000 participants 65 years or older evaluating the effectiveness of PCV13 demonstrated how the vaccine offers moderate protection against the most common forms of pneumococcal community-acquired pneumonia in healthy elderly people.…”

“…5 Live attenuated vaccines Live attenuated vaccines should be administered at least 4 weeks prior to immunosuppressive therapy. 5,6 The recommendations by the Centers for Disease Control and the Infectious Diseases Society of America (IDSA), is that vaccination after chemotherapy should not occur until at least 3 months after the discontinuation of the immunosuppressive therapy, except for patients receiving regimens that include anti-B-cell antibodies, in which case, vaccination should be delayed for at least 6 months after treatment. 7 However, the treating physician should carefully consider the use of live attenuated vaccines, as some other chemotherapy agents would cause immunosuppression for over 3 months.…”

“…6 Therefore, physicians should carefully evaluate and discuss these vaccines' risk-benefit profile with their patients before making a recommendation regarding their use. Live attenuated vaccines could be administered at least 4 weeks before the initiation of highly immunosuppressive therapy and at least 3 months after the completion of chemotherapy; the timing of vaccination after chemotherapy may be much later depending on the immunosuppressive agents used.…”

“…10 Most data on vaccination in cancer patients are from underpowered studies that include patients with different cancers and chemotherapy treatments and that use diverse definitions of vaccine response. 6 Classically, vaccine response is measured by assessing pre-and post-vaccination antibody titers (Immunoglobulin G), which should be performed by the same laboratory. The precise methods used to measure vaccine response vary depending on the vaccine as well as the antibody titer cut-off level used to indicate protection.…”