Immunization of children with cancer is a burning topic. Not only concerned parents but also paediatric oncologists have so many questions and queries regarding this matter. This presentation will try to answer those questions with the help of recent and updated guidelines on immunization of both developed and developing countries.

1. Presenters:
DR. RENESHA ISLAM
RESIDENT (PHASE-B)
PAEDIATRIC HAEMATOLOGY & ONCOLOGY
BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY
(BSMMU)
WELCOME TO SEMINAR

2. Case Scenario: 01
Noor Muhammad, a 7yrs old boy,
diagnosed case of AML. During
“Measles-Rubella campaign 2020”
his mother asked whether Noor
can receive vaccine?
2
Answer: NO.

3. Case Scenario: 02
Nawaf, a 5yrs old boy, diagnosed
case of ALL. He has an younger
sibling named Noirit, aged
2months. Mother’s query was
whether Noirit can receive Rota
virus vaccine?
3
Answer: YES.

4. Frequently asked questions
 Which vaccines are contraindicated during chemotherapy?
 If contraindicated, then what measures should be taken
when patient becomes exposed to that micro-organism?
 After completion of chemotherapy, from when the survivor
can start vaccination?
 Which vaccines can be used safely during ongoing
chemotherapy?
 Whether Siblings, caregiver/parents can receive vaccine?
4

5. IMMUNIZATION IN CHILDREN WITH
CANCER
5

6. introduction
Pediatric cancers are now-a-days largely curable, with very
high cure rates in the developed countries and steadily
improving outcomes in the developing countries.
Immunization for vaccine preventable diseases is
important in children with cancer as it can reduce non
cancer related morbidity/mortality and contribute
favorably to the overall outcome in these children.
6

7.  For this reason, many developed
countries have formulated guidelines for
vaccinating children with cancer during
their treatment as well as after the
completion of treatment, in line with
their national immunization schedules.
7

8. Factors Guiding Immunization Of Children With
Cancer During & After Treatment
 Immunization status prior to starting cancer treatment,
current immunization schedule e.g. NAP (National
Immunization Programme) or UIP (Universal Immunization
Programme).
 Risk of getting exposed to vaccine-preventable disease
during treatment e.g. hepatitis B.
 Degree of immune suppression which depends on the
intensity, duration & nature of chemotherapeutic agents.
8

9.  Nature of pediatric cancers which range from minimal
involvement of the immune system in children with
localized solid malignancies to extensive immune
suppression due to pancytopenia at presentation in
acute leukemia.
 Some diseases present with specific immune
involvement e.g. Hodgkin lymphoma, Burkitts
lymphoma associated with lack of lymphocytic
response to various antigens and variable levels of
lymphocyte depletion, respectively.
9

10. Guidelines
 National guidelines by Infectious Disease Society of America(IDSA).
 Guidelines on Vaccinations in Pediatric Hematology and Oncology
Patients by BioMed Research International.
 The Australian Immunization handbook.
 Royal College of Pediatrics and Child Health [RCPCH].
 Guidelines for the immunization of children following treatment
with Standard-Dose Chemotherapy and HSCT by Birmingham
Children’s Hospital.
 Guidebook on Immunization by Indian Academy of Pediatrics(IAP).
10

11. Conflicts
 Re-immunization: IDSA recommends re-immunization of
children from 3 months following the end of their cancer
chemotherapy, whereas other would recommend a gap
of 6 months from end of treatment.
 Coverage: Guidelines of developing countries do not
cover all vaccines, including some vaccines of local
importance in developed countries.
11

12. Conflicts
Some guidelines does not cover-
 Those children who have received myeloablative
chemotherapy e.g. those undergoing stem cell transplant.
 Those who only received surgery and/or local radiotherapy for
their cancer treatment e.g. low grade gliomas.
 Children treated with targeted therapy including monoclonal
antibodies, small molecule targeted agents and other
modalities of immunotherapy that are currently being
increasingly used in the management of Childhood cancer.
12

13. RECOMMENDATIONS FOR LIVE VACCINES
13

14. 14
Vaccine During
chemotherapy
After end of chemotherapy Maximum
age limit for
vaccination
Previously
unimmunized
Children with completed
immunization
BCG Not
recommen-
ded.
Single dose
BCG at 6 month
after
completion of
chemotherapy.
Not recommended in
previously
immunized children
with visible
BCG scar.
5
Years.

15. 15
Vaccine During
chemotherapy
After end of chemotherapy Maximum
age limit for
vaccination
Previously
unimmunized
Children with completed
immunization
OPV Not
recommen-
ded.
IPV preferred.
When
unavailable, 3
doses of bOPV
1month apart.
IPV preferred.
When unavailable,
2 doses of bOPV
1month apart.
5
Years.

16. 16
Vaccine During
chemotherapy
After end of chemotherapy Maximum
age limit for
vaccination
Previously
unimmunized
Children with
completed
immunization
MMR Not
recommen-
ded.
2 doses of MMR
(1-3 months apart)
should be given to
all children after at
least 6 month of
completion of
chemotherapy.
Single dose of
MMR should be
given to all
children after at
least 6 month of
completion of
chemotherapy.
No upper
age limit.

17. Post Exposure Prophylaxis
Of Measles During
Chemotherapy
+ Ribavirin and
+ Intravenous immuno-
globulin (IVIg) have been tried.
17

18. 18
Vaccine During
chemotherapy
After end of chemotherapy Maximum
age limit for
vaccination
Previously unimmunized Children with
completed
immunization
Varicella
vaccine
Not
recommen-
ded.
2 doses, after 6
month of
completing
chemotherapy.
Age dependent schedule
<13yr: 2 doses
>3months apart.
>13yr: 2 doses
>1months apart.
Single booster
dose is
recommended
after 6 month of
completing
chemotherapy.
No age
limit.

19. Under ideal circumstances, VZV
IgG levels should be assessed at
the time of exposure & children
with less than protective levels-
 Varicella Zoster
Immunoglobulin (VZIg/IVIg)
or
 Oral acyclovir.
19
Post Exposure Prophylaxis Of
Varicella Infection During
Chemotherapy

20. 20
VZIg IVIg ACYCLOVIR PROPHYLAXIS
• 0-5yrs- 250 mg,
• 6-10 yrs- 500 mg,
• 11-14yrs- 750 mg
• ≥15 years 1000 mg
by slow I/M.
0.2g/kg
I/V
If both (VZIg/IVIg) are unaffordable
High dose oral
• <2yrs 200 mg QID
• 2-6yrs 400 mg QID
• >6 years 800 mg QID has to be
started from day 7 and continued
till day 21 from the time of
exposure.

21. 21
Vaccine During
chemotherapy
After end of chemotherapy Maximum
age limit for
vaccination
Previously
unimmunized
Children with
completed
immunization
Live
Attenuated
HAV
Not
recommen-
ded.
Single dose after 6 month of
completing chemotherapy.
No age
limit.

22. 22
Vaccine During chemotherapy After end of chemotherapy Maximum
age limit for
vaccination
Previously
unimmunized
Children with
completed
immunization
ROTA
VIRUS
VACCINE
Not
recommended.
Generally child outgrows the
maximum permissible age,
therefore,
not indicated.
12
months
of age.

23. RECOMMENDATIONS FOR NON-LIVE VACCINES
23

24. 24
Vaccine During
chemotherapy
After end of chemotherapy Maximum
age limit for
vaccination
Previously unimmunized Children with completed
immunization
DPT Not
recommen-
ded.
3 doses at 0,1 and 6
month (6 month after
stopping chemotherapy)
DwPT/DaPT: <7 years.
TdaP 1st dose
followed by given as Td
2nd & 3rd dose if > 7
years of
age.
Single booster dose
(6 month after
stopping
chemotherapy).
DwPT/DaPT: <7
years.
TdaP: > 7 years of
age.
7
Years.

25. 25
Vaccine During
chemotherapy
After end of chemotherapy Maximum
age limit for
vaccination
Previously unimmunized Children with
completed
immunization
Hib Not
recommen-
ded.
After 6 month of
completing chemotherapy.
Age dependent schedule
6-12 months: 2 doses 8 weeks
apart followed by booster at
12month.
12-15months: 1 dose & booster
at 18months.
15-60 months: 1 dose.
Single booster
dose
(6 month after
stopping
chemotherapy).
5
Years.

26. 26
Vaccine During
chemotherapy
After end of chemotherapy Maximum
age limit for
vaccination
Previously
unimmunized
Children with completed
immunization
IPV Not
recommen-
ded.
2 doses of IPV 2
months apart &
3rd dose after
6 months
(6 month after
stopping
chemotherapy)
Single booster dose
(6 month after
stopping
chemotherapy).
Two doses of IPV
1month apart for
those who received
OPV as primary
immunization.
5
Years.

27. 27
Vaccine During chemotherapy After end of chemotherapy Maximum
age limit for
vaccination
Previously
unimmunized
Children with
completed
immunization
HBV Generally not recommended. If there is
risk of suboptimal blood transfusion
practices in an unimmunized child &
hepatitis B surface antigen (-ve), 4 doses of
vaccine (0, 1, 2 & 12 months at double
dose for previously unimmunized children
as well as age appropriate dose of
hepatitis B Ig every 3 months till there is
no risk of exposure to blood products.
No further doses for children who
completed primary schedule prior to
diagnosis.
3 doses at 0, 1
& 6 month (6
months after
stopping
chemotherapy.
Single booster
dose (6 month
after stopping
chemotherapy)
No age
limit.

28. 28
Vaccine During
chemotherapy
After end of chemotherapy Maximum
age limit for
vaccination
Previously
unimmunized
Children with completed
immunization
HAV Not
recommen-
ded.
2 doses 6
month apart.
(6 month after
completion of
chemotherapy)
Single booster dose
about 6 month after
completion of
chemotherapy.
No age
limit.

29. 29
Vaccine During chemotherapy After end of
chemotherapy
Maximum
age limit for
vaccination
Previously
unimmunized &
Children with
completed
immunization
Inactivated
influenza
vaccine
Recommended single dose annually.
6 months- 9 years – 2 doses 1 month
apart & then single dose every year till
indicated.
>9 years – single dose every year till
indicated.
Usually not
recommended
routinely beyond
1 yr from the end
of chemotherapy.
No age
limit.

30. 30
Vaccine During
chemotherapy
After end of chemotherapy Maximum
age limit
for
vaccination
Previously unimmunized Children with
completed
immunization
Pneumococcal
vaccine
Not
recommended.
6 month after stopping of
chemotherapy.
Age dependant schedule
<1 yr: 2 doses at 4-8 week
interval followed by a booster
dose 12-15 months age.
1-2 yr: 2 doses 4-8 weeks
apart.
2-5 yrs: single dose.
Single
booster
dose about
6 month
after
stopping of
chemo-
therapy.
5
Years.

31. 31
Vaccine During chemotherapy
After end of chemotherapy Maximum
age limit for
vaccination
Previously
unimmunized
Children with
completed
immunization
Inactivated
Typhoid
Vaccine
Not
recommended. Single dose of typhoid
conjugate vaccine.
(6 month after stopping
of chemotherapy)
No booster doses are
recommended.
No upper
age limit.

32. 32
Vaccine During
chemotherapy
After end of chemotherapy Maximum
age limit for
vaccination
Previously unimmunized Children with
completed
immunization
HPV Not
recommen-
ded.
6 month after
stopping of
chemotherapy.
Age dependent schedule
9-14yr: 2 doses
6months apart
>14 yr: 3 doses at 0,
2, 6 months.
Insufficient data
on booster dose
but single booster
dose may be
considered in
females.
45
Years.

33. • Proper & thorough wound management & antisepsis
accompanied by local infiltration of Rabies
Immunoglobulin followed by anti-rabies vaccination are
of utmost importance.
• Even patients with category II exposures should receive
rabies immunoglobulin in addition to a full post-exposure
vaccination including the 6th dose on day 90 which is also
mandatory.
33
Post Exposure Prophylaxis (Rabies Vaccine)

34. 34
Tetanus Prophylaxis in wound management During
Chemotherapy
 All patients presenting with skin wounds/infections
should be evaluated for tetanus prophylaxis.
 Cleaning of the wound, removal of devitalized tissue,
irrigation and drainage is important to prevent
anaerobic environment which is conducive to tetanus
toxin production.

35. 35
Tetanus Prophylaxis in wound management During
Chemotherapy
Clean, minor wound –
Td/TdaP booster regardless of immunization status is
Recommended.
For all other wounds –
Td/TdaP + Tetanus Immuno Globulin is advised.

36. 36
Other Vaccine
Other non-live vaccines like Meningococcal vaccine,
Japanese encephalitis vaccine, Cholera vaccine and Yellow
fever vaccine are not routinely recommended also have no
specific role in children with cancer during or after
treatment.

37. Immunization in asplenia/hyposplenia
37
• In childhood cancer patients, asplenia or hyposplenia
may result from radiation therapy involving spleen.
• Occasionally splenectomy may be part of local control of
cancer.
• These children are at a high risk of serious infection with
encapsulated organisms.

38. Immunization in asplenia/hyposplenia
38
• In addition to routine vaccines, immunization with
pneumococcal (both conjugate and polysaccharide),
hemophilus influenzae type B, meningococcal and
typhoid vaccines are indicated.
• If splenectomy is planned, immunization should be
initiated at least 2 weeks prior to splenectomy to
achieve a superior immunologic response.

39. Immunization of Contacts of Children with Cancer
39

40. Siblings
• All non-live vaccines are allowed as per immunization
schedule.
• Inactivated influenza vaccine is recommended.
• Live vaccines like BCG, MMR, Varicella, Rotavirus, Yellow
fever vaccine are also allowed as per scheduled.
• OPV is contraindicated including pulse polio immunization
days. Sibling should receive IPV & if either is given by
mistake or given because of lack of option, then the
sibling should remain away from index child for at least 2
weeks.
40

41. + Varicella vaccine is encouraged in the unimmunized
sibling who has not had chicken-pox before and if the
sibling develops varicella vaccine induced rash, then the
sibling should stay away from index child till all lesions
crust.
+ Rotavirus vaccine is not discouraged but child with cancer
should refrain from changing diapers of the vaccinated
infant till 4 weeks from day of vaccination.
41
Siblings

42. Parents
Inactivated Influenza vaccine is strongly
recommended. Varicella vaccine is also
encouraged in the unimmunized parent who has
not had chicken-pox before and if the parent
develops varicella vaccine induced rash, then
the parent should stay away from index child.
42

43. Recommendations For Vaccination Of Hematopoietic
Stem Cell transplant Patients
Prior to HSCT, candidates should receive vaccines based on
age, vaccination history & exposure history. (For ex: Non
immune HSCT candidates aged ≥12m should receive VAR
(2-dose regimen if there is sufficient time) if they are not
already immunosuppressed & when the interval to start of
the conditioning regimen is ≥4 weeks for live vaccines & ≥2
weeks for inactivated vaccines.
43

44. Recommendations For Vaccination Of Hematopoietic
Stem Cell transplant Donor
• The HSCT donor should be current with routinely
recommended vaccines based on age, vaccination
history & exposure history.
• However, administration of MMR, MMRV, VAR, and ZOS
vaccines should be avoided within 4 weeks of stem cell
harvest. Vaccination of the donor for the benefit of the
recipient is not recommended.
44

45. Vaccination After HSCT
• 1 dose of IIV should be administered annually to persons
aged ≥6 months starting 6 months after HSCT & starting 4
months after if there is a community outbreak of
influenza as defined by the local health department.
• For children aged 6m–8yrs who are receiving influenza
vaccine for the first time, 2doses should be administered.
• 3 doses of PCV should be administered to children
starting at age 3–6 months after HSCT.
45

46. Vaccination After HSCT
• 3 doses of Hib: 6–12 months after HSCT.
• 2 doses of MCV4: 6–12 months after HSCT to persons
aged 11–18 years, with a booster dose given at age 16–18
years for those who received the initial post-HSCT dose of
vaccine at age 11–15 years.
• 3 doses of Tetanus/Diphtheria–containing Vaccine: 6
months after HSCT.
• 3 doses of HepB vaccine: 6–12 months after HSCT.
46

47. Vaccination After HSCT
• 3 doses of IPV vaccine: 6–12months after HSCT.
• 3 doses of HPV vaccine 6–12months after HSCT for
female patients aged 11–26 years and HPV4 vaccine for
males aged 11–26 years.
• 2-dose of MMR vaccine: Measles-sero(-ve) children 24
months after HSCT in patients with neither chronic GVHD
nor ongoing immunosuppression & 8–11months (or
earlier if there is a measles outbreak) after the last dose
of immune globulin intravenous (IGIV).
47

48. Vaccination After HSCT
• Live vaccines to HSCT patients with active GVHD or
ongoing immunosuppression.
• 2-dose series of VAR should be administered 24 months
after HSCT to varicella-sero negative patients with
neither GVHD nor ongoing immunosuppression and 8–11
months after the last dose of IGIV.
48

49. 49

50. COVID-19 Vaccine
On 11th Dec, 2020, the FDA granted emergency use
authorization (EUA) to a vaccine from Pfizer-BioNTech – the
first COVID-19 vaccine authorized in the U.S. One week
later, on 18th Dec, 2020 the FDA granted EUA to a vaccine
from Moderna. Both vaccines were more than 90% effective
in preventing illness from COVID-19 among clinical trial
participants. Both are given in two doses 3-4weeks apart.
The Pfizer-BioNTech vaccine is authorized for use in anyone
16 and older, while the Moderna vaccine is authorized for
people 18 and older.
50

51. COVID-19 Vaccine & cancer patient
Both vaccines were shown to be safe in clinical trials and
more than 4.5 million Americans (and counting) have
received at least one vaccine dose so far. At this time,
patients undergoing cancer treatment or who have
completed cancer treatment, may be offered vaccination
against COVID-19 if they have no other contraindications to
these vaccines. Even after vaccination, cancer patients
should continue to follow current guidance including
wearing masks, social distancing and frequent hand washing
to protect themselves from exposure to COVID-19.
51

52. COVID-19 Vaccine & Pediatric Cancer
However, most COVID-19 vaccine clinical trials have not yet
included pediatric cancer patients, so important questions
remain about how well these vaccines induce immunity in
patients with cancer, particularly those undergoing
treatment. Because children’s immune systems are
different from those of adults, pediatric clinical trials are
essential to establish safety and efficacy of COVID-19
vaccines among children. As some pediatric trials are just
getting started, it will be some time before we see a vaccine
available for kids – likely later into 2021.
52

53. Take Home Message
+ Post-treatment re-immunization/catch-up schedule
largely depends on the pre-chemotherapy immunization
status.
+ Live vaccines are contraindicated during and up to 6
months after end of chemotherapy.
+ Non-live vaccines are also best given after 6 months from
the end of treatment for durable immunity.
53

54. + Annual inactivated influenza vaccine is the only vaccine
recommended for all children during chemotherapy
whereas hepatitis B vaccine is recommended only for
previously unimmunized children with risk of transfusion
associated transmission of infection.
+ Sibling immunization should continue uninterrupted
except for OPV which needs to be substituted by the
injectable vaccine. Inactivated influenza vaccine is
recommended & varicella vaccine is encouraged for all
contacts including siblings.
54
Take Home Message

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Thank you all