The influence of chemotherapy on response of patients with hematologic malignancies to influenza vaccine

Efficacy of influenza vaccine (Fluvax) in cancer patients on treatment: a prospective single arm, open-label study

PURPOSE

Influenza virus infection has significant morbidity and mortality in patients with medical co-morbidities who are also immunosuppressed. The efficacy of the seasonal influenza vaccine has not been well studied in patients receiving chemotherapy. We assessed the efficacy of seasonal influenza vaccine in patients with non-haematological malignancy on active treatment (chemotherapy and targeted therapy).

METHODS

A prospective single arm, open label study with 53 patients with non-haematological cancers recruited during the 2011 and 2012 influenza seasons. Participants had one dose of 2011/2012 trivalent vaccine containing strains A/California/7/2009(H1N1), A/Perth/16/2009 (H3N2) and B/Brisbane/60/2008 (Fluvax) prior to or in-between treatment cycles. Haemagglutination inhibition antibody (HIA) titres in serum were measured at baseline 3, 6 and 24 weeks. Primary endpoint: seroconversion rate (SCR) at 3 weeks. Secondary endpoints: late SCR at 6 weeks. rate of sustained sero-protection titres (SPR) at 24 weeks. Seroconversion was defined as postvaccination ≥ 4-fold increase in HIA titre and sero-protection defined as a HIA ≥ 1:40.

RESULTS

The SCR at 3 weeks were 35%, 30% and 22.5% to the H1N1, H3N2 and B/Bris strains, respectively. There were no new cases of late SC at 6 weeks or 24 weeks. The SPR at 3 weeks were 72.5%, 65% and 40%, respectively, to H1N1, H3N2 and B/Bris. The SPR at 24 weeks to H1N1, H3N2 and B/Bris were 40%, 52.5% and 17.5%, respectively.

CONCLUSIONS

Patients on various solid tumour treatments achieve sero-protection rate congruent with the general population. The sero-protection HIA titres were not sustained at 24 weeks postvaccination.

Influenza vaccines in immunosuppressed adults with cancer

BACKGROUND

This is an update of the Cochrane review published in 2013, Issue 10.Immunosuppressed cancer patients are at increased risk of serious influenza-related complications. Guidelines, therefore, recommend influenza vaccination for these patients. However, data on vaccine effectiveness in this population are lacking, and the value of vaccination in this population remains unclear.

OBJECTIVES

To assess the effectiveness of influenza vaccine in immunosuppressed adults with malignancies. The primary review outcome is all-cause mortality, preferably at the end of the influenza season. Influenza-like illness (ILI, a clinical definition), confirmed influenza, pneumonia, any hospitalisations, influenza-related mortality and immunogenicity were defined as secondary outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and LILACS databases up to May 2017. We searched the following conference proceedings: ICAAC, ECCMID, IDSA (infectious disease conferences), ASH, ASBMT, EBMT (haematological), and ASCO (oncological) between the years 2006 to 2017. In addition, we scanned the references of all identified studies and pertinent reviews. We searched the websites of the manufacturers of influenza vaccine. Finally, we searched for ongoing or unpublished trials in clinical trial registry databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs), prospective and retrospective cohort studies and case-control studies were considered, comparing inactivated influenza vaccines versus placebo, no vaccination or a different vaccine, in adults (16 years and over) with cancer. We considered solid malignancies treated with chemotherapy, haematological cancer patients treated or not treated with chemotherapy, cancer patients post-autologous (up to six months after transplantation) or allogeneic (at any time) haematopoietic stem cell transplantation (HSCT).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias and extracted data from included studies adhering to Cochrane methodology. Meta-analysis could not be performed because of different outcome and denominator definitions in the included studies.

MAIN RESULTS

We identified six studies with a total of 2275 participants: five studies comparing vaccination with no vaccination, and one comparing adjuvanted vaccine with non-adjuvanted vaccine. Three studies were RCTs, one was a prospective observational cohort study and two were retrospective cohort studies.For the comparison of vaccination with no vaccination we included two RCTs and three observational studies, including 2202 participants. One study reported results in person-years while the others reported results per person. The five studies were performed between 1993 and 2015 and included adults with haematological diseases (three studies), patients following bone marrow transplantation (BMT) (two studies) and solid malignancies (three studies).One RCT and two observational studies reported all-cause mortality; the RCT showed similar mortality rates in both arms (odds ratio (OR) 1.25 (95% CI 0.43 to 3.62; 1 study, 78 participants, low-certainty evidence)); and the observational studies demonstrated a significant association between vaccine receipt and lower risk of death, adjusted hazard ratio 0.88 (95% CI 0.78 to 1; 1 study, 1577 participants, very low-certainty evidence) in one study and OR 0.42 (95% CI 0.24 to 0.75; 1 study, 806 participants, very low-certainty evidence) in the other. One RCT reported a reduction in ILI with vaccination, while no difference was observed in one observational study. Confirmed influenza rates were lower with vaccination in one RCT and the three observational studies, the difference reaching statistical significance in one. Pneumonia was observed significantly less frequently with vaccination in one observational study, but no difference was detected in another or in the RCT. One RCT showed a reduction in hospitalisations following vaccination, while an observational study found no difference. No life-threatening or persistent adverse effects from vaccination were reported. The strength of evidence was limited by the low number of included studies and by their low methodological quality and the certainty of the evidence for the mortality outcome according to GRADE was low to very low.For the comparison of adjuvanted vaccine with non-adjuvanted vaccine, we identified one RCT, including 73 patients. No differences were found for the primary and all secondary outcomes assessed. Mortality risk ratio was 0.54 (95% CI 0.05 to 5.73; low-certainty evidence) in the adjuvanted vaccine group. The quality of evidence was low due to the small sample size and the large confidence intervals for all outcomes.

AUTHORS' CONCLUSIONS

Observational data suggest lower mortality and infection-related outcomes with influenza vaccination. The strength of evidence is limited by the small number of studies and low grade of evidence. It seems that the evidence, although weak, shows that the benefits overweigh the potential risks when vaccinating adults with cancer against influenza. However, additional placebo or no-treatment controlled RCTs of influenza vaccination among adults with cancer is ethically questionable.There is no conclusive evidence regarding the use of adjuvanted versus non-adjuvanted influenza vaccine in this population.

Improved Survival of HER2+ Breast Cancer Patients Treated with Trastuzumab and Chemotherapy Is Associated with Host Antibody Immunity against the HER2 Intracellular Domain

The addition of trastuzumab to chemotherapy extends survival among patients with HER2(+) breast cancer. Prior work showed that trastuzumab and chemotherapy augments HER2 extracellular domain (ECD)-specific antibodies. The current study investigated whether combination therapy induced immune responses beyond HER2-ECD and, importantly, whether those immune responses were associated with survival. Pretreatment and posttreatment sera were obtained from 48 women with metastatic HER2(+) breast cancer on NCCTG (now Alliance for Clinical Trials in Oncology) studies, N0337 and N983252. IgG to HER2 intracellular domain (ICD), HER2-ECD, p53, IGFBP2, CEA, and tetanus toxoid were examined. Sera from 25 age-matched controls and 26 surgically resected HER2(+) patients were also examined. Prior to therapy, some patients with metastatic disease had elevated antibodies to IGFBP2, p53, HER2-ICD, HER2-ECD, and CEA, but not to tetanus toxin, relative to controls and surgically resected patients. Treatment augmented antibody responses to HER2-ICD in 69% of metastatic patients, which was highly associated with improved progression-free survival (PFS; HR = 0.5, P = 0.0042) and overall survival (OS; HR = 0.7, P = 0.038). Augmented antibody responses to HER2-ICD also correlated (P = 0.03) with increased antibody responses to CEA, IGFBP2, and p53, indicating that treatment induces epitope spreading. Paradoxically, patients who already had high preexisting immunity to HER2-ICD did not respond to therapy with increased antibodies to HER2-ICD and demonstrated poorer PFS (HR = 1.6, P < 0.0001) and OS (HR = 1.4, P = 0.0006). Overall, the findings further demonstrate the importance of the adaptive immune system in the efficacy of trastuzumab-containing regimens. Cancer Res; 76(13); 3702-10. ©2016 AACR.

Influenza vaccination in cancer patients undergoing systemic therapy

BACKGROUND

Cancer patients often experience preventable infections, including influenza A and B. These infections can be a cause of significant morbidity and mortality. The increased risk of infection may be because of either cancer itself or treatment-induced immunosuppression.1 Influenza immunization has been shown to decrease the risk of influenza infection in patients with intact immunity.2 In cancer patients, active immunization has been shown to confer protective immunity against several infections at similar rates to healthy individuals, which has translated into decreased duration and severity of infection and potentially improved morbidity and mortality.3

OBJECTIVES

SEARCH METHODS

We searched MEDLINE/PubMed database for articles published from 1964 to 2013 using the search terms “cancer,” “adult,” “influenza vaccination,” and “chemotherapy.”

SELECTION CRITERIA

We included studies based on systematic sampling with defined clinical criteria irrespective of the vaccination status of cancer patients. Studies measure the serological response or clinical response to compare between the study group and the control group. Studies assessed the inactivated influenza vaccines and live attenuated influenza vaccine (LAIV) protective serological reaction and the clinical outcomes after vaccination.

DATA COLLECTION AND ANALYSIS

Two independent authors assessed the methodological quality of included studies and extracted data.

MAIN RESULTS

We included 16 studies (total number of participants = 1,076). None of the included studies reported clinical outcomes. All included studies reported on influenza immunity and adverse reaction on vaccination. We included 6 solid tumor studies and 10 hematological studies. In 12 studies, the serological response to influenza vaccine was compared in patients receiving chemotherapy (n = 425) versus those not receiving chemotherapy (n = 376). In three studies, the serological responses to influenza vaccination in patients receiving chemotherapy are compared to that in healthy adult. Measures used to assess the serological responses included a four-fold rise increase in antibody titer development of hemagglutination inhibition (HI) titer >40, and pre- and post-vaccination geometric mean titers (GMTs). Immune responses in patients receiving chemotherapy were consistently weaker (four-fold rise of 17–52%) than in those who had completed chemotherapy (50–83%) and healthy patients (67–100%). Concerning adverse effects, oncology patients received influenza vaccine, and the side effects described were mild local reactions and low-grade fever. No life-threatening or persistent adverse effects were reported.

AUTHORS’ CONCLUSION

Patients with solid and some of hematological tumors are able to mount a serological response to influenza vaccine, but it remains unclear how much this response protects them from influenza infection or its complications. Meanwhile, influenza vaccine appears to be safe in these patients. While waiting results of randomized controlled trials to give us more details about the clinical benefits of the influenza vaccination, the clinicians should consider the currently proved benefits of influenza vaccination on management of the cancer patients undergoing systematic chemotherapy such as decrease in the duration and severity of the of the disease, and significant decrease in influenza-associated morbidity and mortality in these high-risk patients.3

Immunogenicity of influenza vaccine in colorectal cancer patients

Purpose

Although influenza is regarded as a major cause of morbidity and mortality in immunocompromised patients, vaccine coverage remains poor. We evaluated the immunogenicity of influenza vaccines in colorectal cancer patients.

Materials and Methods

In this study, 40 colorectal cancer patients who received an influenza vaccine at the Korea Cancer Center Hospital during the 2009-2010 and 2010-2011 influenza seasons were analyzed. The blood samples were collected at prevaccination and 30 days post vaccination, and antibody titers were measured using the hemagglutination-inhibition tests.

Results

In the 2009-2011 season, the seroprotection rate for H1N1 (94.7%) was significantly higher than that for H3N2 (42.1%) and B (47.3%). The seroconversion rate was 52.6%, 26.3%, and 36.8% for H1N1, H3N2, and B, respectively. Fold increase of geometric mean titer (MFI) was 3.86, 1.49, and 3.33 for H1N1, H3N2, and B, respectively. In the 2010-2011 season, the seroprotection rate for H1N1 (57.1%) was significantly higher than that for H3N2 (52.4%) and B (38.1%). The seroconversion rate was 52.4%, 47.6% and 33.3% for H1N1, H3N2, and B, respectively. MFI was 12.29, 3.62 and 4.27 for H1N1, H3N2, and B, respectively.

Conclusion

Our study cohort showed an acceptable immune response to an influenza vaccine without significant adverse effects, supporting the recommendation for annual influenza vaccination in colorectal cancer patients.

Influenza vaccines in immunosuppressed adults with cancer

BACKGROUND

Immunosuppressed cancer patients are at increased risk of serious influenza-related complications. Guidelines, therefore, recommend influenza vaccination for these patients. However, data on vaccine effectiveness in this population is lacking, and the value of vaccination in this population remains unclear.

OBJECTIVES

To assess the effectiveness of influenza vaccine in immunosuppressed adults with malignancies. The primary review outcome is all-cause mortality, preferably at the end of the influenza season. Influenza-like illness (ILI, a clinical definition), confirmed influenza, pneumonia, any hospitalization and influenza-related mortality were defined as secondary outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and LILACS databases up to August 2013. We searched the following conference proceedings: ICAAC, ECCMID, IDSA (infectious disease conferences), ASH, ASBMT, EBMT (hematological), and ASCO (oncological) between the years 2006 to 2010. In addition, we scanned the references of all identified studies and pertinent reviews. We searched the websites of the manufacturers of influenza vaccine. Finally, we searched for ongoing or unpublished trials in clinical trial registry databases using the website.

SELECTION CRITERIA

Randomized controlled trials (RCTs), prospective and retrospective cohort studies and case-control studies were considered, comparing inactivated influenza vaccines versus placebo, no vaccination or a different vaccine, in adults (16 years and over) with cancer. We considered solid malignancies treated with chemotherapy, haematological cancer patients treated or not treated with chemotherapy, cancer patients post-autologous (up to six months after transplantation) or allogeneic (at any time) hematopoietic stem cell transplantation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias and extracted data from included studies adhering to Cochrane methodology. Meta-analysis could not be performed because of different outcome and denominator definitions in the included studies.

MAIN RESULTS

We identified four studies: one RCT and three observational studies, including 2124 participants. One study reported results in person-years while the other three reported per person. The studies were performed between 1993 and 2012 and included adults with haematological diseases (two studies), patients following bone marrow transplantation (one study) and solid malignancies (three studies). Only two observational studies reported all-cause mortality; one showing an adjusted hazard ratio (HR) of 0.88 (95% CI 0.77 to 0.99) for death with vaccination and the other reporting an odds ratio (OR) of 0.43 (95% CI 0.26 to 0.71). The RCT reported a statistically significant reduction in ILI with vaccination, while no difference was observed in one observational study. Confirmed influenza rates were lower with vaccination in the three observational studies, the difference reaching statistical significance in one. Pneumonia was observed significantly less frequently with vaccination in one observational study, but no difference was detected in another or in the RCT. The RCT showed a reduction in hospitalizations following vaccination, while an observational study found no difference. No life-threatening or persistent adverse effects from vaccination were reported. The strength of evidence is limited by the low number of included studies and by their low methodological quality (high risk of bias).

AUTHORS' CONCLUSIONS

Observational data suggests a lower mortality with influenza vaccination. Infection-related outcomes were lower or similar with influenza vaccination. The strength of evidence is limited by the small number of studies and by the fact that only one was a RCT. Influenza vaccination is safe and the evidence, although weak, is in favour of vaccinating adults with cancer receiving chemotherapy.

Influenza vaccination in children being treated with chemotherapy for cancer

BACKGROUND

Influenza infection is a potential cause of severe morbidity in children with cancer; therefore vaccination against influenza is recommended. However, data are conflicting regarding the immune response to influenza vaccination in children with cancer, and the value of vaccination remains unclear.

OBJECTIVES

1. To assess the efficacy of influenza vaccination in stimulating an immunological response in children with cancer during chemotherapy, compared with control groups.2. To assess the efficacy of influenza vaccination in preventing confirmed influenza and influenza-like illness and/or in stimulating immunological response in children with cancer treated with chemotherapy, compared with placebo, no intervention or different dosage schedules.3. To identify the adverse effects associated with influenza vaccines in children with cancer treated with chemotherapy, compared with other control groups.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to 2012) and EMBASE (1980 to 2012) up to August 2012. We also searched reference lists of relevant articles and conference proceedings of the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), the Infectious Diseases Society of America (IDSA), the Multinational Association of Supportive Care in Cancer (MASCC) and the International Society of Paediatric Oncology (SIOP).

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) and controlled clinical trials (CCTs) in which the serological response to influenza vaccination of children with cancer was compared with that of control groups. We also considered RCTs and CCTs that compared the effects of influenza vaccination on clinical response and/or immunological response in children with cancer being treated with chemotherapy, compared with placebo, no intervention or different dosage schedules.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed the methodological quality of included studies and extracted the data.

MAIN RESULTS

We included 1 RCT and 9 CCTs (total number of participants = 770). None of the included studies reported clinical outcomes. All included studies reported on influenza immunity and adverse reactions to vaccination. In five studies, immune responses to influenza vaccine were compared in 272 children receiving chemotherapy and 166 children not receiving chemotherapy. In four studies, responses to influenza vaccine were assessed in 236 children receiving chemotherapy compared with responses in 142 healthy children. Measures used to assess immune responses included a four-fold rise in antibody titre after vaccination, development of a haemagglutination inhibition (HI) titre > 32 and pre- and post-vaccination geometric mean titres (GMTs). Immune responses in children receiving chemotherapy were consistently weaker (four-fold rise of 38% to 65%) than those in children who had completed chemotherapy (50% to 86%) and in healthy children (53% to 89%). In terms of adverse effects, 391 paediatric oncology patients received influenza vaccine, and the adverse effects described included mild local reactions and low-grade fever. No life-threatening or persistent adverse effects were reported.

AUTHORS' CONCLUSIONS

Paediatric oncology patients receiving chemotherapy are able to generate an immune response to the influenza vaccine, but it remains unclear whether this immune response protects them from influenza infection or its complications. We are awaiting results from well-designed RCTs addressing the clinical benefit of influenza vaccination in these patients.

Modeling dendritic cell vaccination for influenza prophylaxis: potential applications for niche populations

BACKGROUND

Cancer patients can exhibit negligible responses to prophylactic vaccinations, including influenza vaccination. To help address this issue, we developed in vitro and in vivo models of dendritic cell (DC) immunotherapy for the prevention of influenza virus infection.

METHODS

Human cord blood (CB)-derived or mouse splenocyte-derived DCs were loaded with purified recombinant hemagglutinin (rHA). T-cell responses to HA-loaded CB-derived DCs were determined by ELISpot. Protective efficacy was determined by vaccination of BALB/c mice with a single injection of 10(6) autologous DCs. DC migration to peripheral lymphoid organs was verified by carboxyfluorescein succinimidyl ester staining, and HA-specific antibody titers were determined by enzyme-linked immunosorbent assay. Mice were then challenged intranasally with BALB/c-adapted A/New Caledonia influenza virus derived from four consecutive lung pool passages. Antigen-presenting cell (APC) dysfunction was modeled using the MAFIA transgenic system, in which the Csf1r promoter conditionally drives AP20178-inducible Fas.

RESULTS

CB-derived human DCs were able to generate de novo T-cell responses against rHA, as determined by a system of rigorous controls. Mice vaccinated intraperitoneally developed HA titers detectable at serum dilutions of >1:1000. HA seroconverters survived virus challenge, whereas unvaccinated controls and vaccinated nonseroconverters lost weight and died. Furthermore, use of a model of APC-specific immunosuppression revealed that DC vaccination could generate HA-specific antibody titers under conditions in which protein vaccination could not.

CONCLUSIONS

The model demonstrates that DC immunotherapy for the prevention of influenza is feasible, and studies are underway to determine whether populations of immunosuppressed individuals might ultimately benefit from the procedure.

Influenza vaccination for immunocompromised patients: systematic review and meta-analysis by etiology

Many national guidelines recommend annual influenza vaccination of immunocompromised patients, although the decision to vaccinate is usually at clinical discretion. We conducted a systematic review and meta-analyses to assess the evidence for influenza vaccination in this group, and we report our results by etiology. Meta-analyses showed significantly lower odds of influenza-like illness after vaccination in patients with human immunodeficiency virus (HIV) infection, patients with cancer, and transplant recipients and of laboratory-confirmed influenza in HIV-positive patients, compared with patients receiving placebo or no vaccination. Pooled odds of seroconversion and seroprotection were typically lower in HIV-positive patients, patients with cancer, and transplant recipients, compared with immunocompetent controls. Vaccination was generally well tolerated, with variation in mild adverse events between etiological groups. Limited evidence of a transient increase in viremia and a decrease in the percentage of CD4(+) cells in HIV-positive patients was found although not accompanied by worsening of clinical symptoms. Clinical judgment remains important when discussing the benefits and safety profile with immunocompromised patients.

Vaccination recommendations for the hematology and oncology and post-stem cell transplant populations

Vaccination is a simple yet important process used to prevent many infections in the general population. For patients with suppressed immune systems, especially those who are undergoing chemotherapy or who have undergone stem cell transplant, repeat vaccination or boosters may be crucial in prolonging and/or extending immunity. The purpose of this review is to examine the need for each vaccine in two separate oncology populations: patients receiving concurrent chemotherapy and post-stem cell transplant patients. In addition, the importance of avoiding live vaccines and criteria for reconsideration at a future time will also be discussed.

A prospective study of the factors shaping antibody responses to the AS03-adjuvanted influenza A/H1N1 vaccine in cancer outpatients

PURPOSE

To identify the determinants of antibody responses to adjuvanted influenza A/H1N1/09 vaccines in a cohort of cancer outpatients.

PATIENTS AND METHODS

Patients with cancer and controls were enrolled in a prospective single-center field study. Two doses of AS03-adjuvanted pandemic influenza vaccine were administered to patients and one dose was administered to controls. Antibody responses were measured using hemagglutination inhibition and confirmed by microneutralization. Geometric mean titers (GMTs) and seroprotection rates (defined as GMTs ≥40) were compared.

RESULTS

Immunizations were safe and well tolerated in 197 cancer patients (lymphoma, 57; glioma, 26; lung or head and neck, 37; gastrointestinal, 41; breast, 36) and 138 controls. Similar seroprotection rates (82.3% versus 87%) and GMTs (336.9 versus 329.9) were achieved after two doses of adjuvanted vaccine in cancer patients and one dose in controls. Univariate analyses identified older age, prior immunization against seasonal influenza, lymphoma, CD4 count, active chemotherapy, and rituximab and steroid treatments as being associated with weaker antibody responses. However, only age and chemotherapy plus rituximab remained independent determinants of vaccine responses in multivariate analyses.

CONCLUSIONS

Two doses of AS03-adjuvanted influenza vaccine elicited potent antibody responses in most cancer patients despite ongoing chemotherapy, with the exception of rituximab-induced B-cell depletion. Oncology patients treated in an outpatient setting benefit from preventive vaccination against influenza with adjuvanted vaccines.

Immunogenicity of an inactivated monovalent 2009 influenza A (H1N1) vaccine in patients who have cancer

BACKGROUND

The immune response of patients who have cancer, who may be receiving immunosuppressive therapy, is generally considered to be decreased. This study aimed to evaluate the immune response of cancer patients to the 2009 influenza A (H1N1) vaccine.

PATIENTS AND METHODS

We conducted a prospective single site study comparing the immune response after H1N1 vaccination of healthy controls (group A), patients who had solid tumors and were taking myelosuppressive chemotherapy (group B), patients who had solid tumors and were taking nonmyelosuppressive or no treatment (group C), and patients who had hematologic malignancies (group D).

RESULTS

At 2-6 weeks after vaccination, seroconversion was observed in 80.0% of group A (95% confidence interval [CI], 65.0%-89.7%), 72.2% of group B (95% CI, 55.9%-84.3%), 87.0% of group C (95% CI, 72.2%-94.7%), and 75.0% of group D (95% CI, 52.8%-89.2%) (p = NS). The geometric mean titer ratio, that is, geometric mean factor increase in antibody titer after vaccination, was 12.6 (95% CI, 7.9-19.9), 12.7 (95% CI, 7.3-22.1), 23.0 (95% CI, 13.9-38.2), and 12.1 (95% CI, 5.3-27.9) (p = NS), and the seroprotection rates were 95.5% (95% CI, 84.0%-99.6%), 79.0% (95% CI, 63.4%-89.2%), 90.5% (95% CI, 77.4%-96.8%), and 90.0% (95% CI, 71%-98.7%) in the corresponding groups (p = NS). Immune responses were robust regardless of malignancy, or time intervals between the use of myelosuppressive or immunosuppressive medications and vaccination. No participants developed clinical H1N1 infection.

CONCLUSION

Cancer patients, whether taking myelosuppressive chemotherapy or not, are able to generate an immune response to the H1N1 vaccine similar to that of healthy controls.

Influenza vaccination for immunocompromised patients: systematic review and meta-analysis from a public health policy perspective

BACKGROUND

Immunocompromised patients are vulnerable to severe or complicated influenza infection. Vaccination is widely recommended for this group. This systematic review and meta-analysis assesses influenza vaccination for immunocompromised patients in terms of preventing influenza-like illness and laboratory confirmed influenza, serological response and adverse events.

METHODOLOGY/PRINCIPAL FINDINGS

Electronic databases and grey literature were searched and records were screened against eligibility criteria. Data extraction and risk of bias assessments were performed in duplicate. Results were synthesised narratively and meta-analyses were conducted where feasible. Heterogeneity was assessed using I(2) and publication bias was assessed using Begg's funnel plot and Egger's regression test. Many of the 209 eligible studies included an unclear or high risk of bias. Meta-analyses showed a significant effect of preventing influenza-like illness (odds ratio [OR]=0.23; 95% confidence interval [CI]=0.16-0.34; p<0.001) and laboratory confirmed influenza infection (OR=0.15; 95% CI=0.03-0.63; p=0.01) through vaccinating immunocompromised patie nts compared to placebo or unvaccinated controls. We found no difference in the odds of influenza-like illness compared to vaccinated immunocompetent controls. The pooled odds of seroconversion were lower in vaccinated patients compared to immunocompetent controls for seasonal influenza A(H1N1), A(H3N2) and B. A similar trend was identified for seroprotection. Meta-analyses of seroconversion showed higher odds in vaccinated patients compared to placebo or unvaccinated controls, although this reached significance for influenza B only. Publication bias was not detected and narrative synthesis supported our findings. No consistent evidence of safety concerns was identified.

CONCLUSIONS/SIGNIFICANCE

Infection prevention and control strategies should recommend vaccinating immunocompromised patients. Potential for bias and confounding and the presence of heterogeneity mean the evidence reviewed is generally weak, although the directions of effects are consistent. Areas for further research are identified.

Immune response to 2009 pandemic H1N1 influenza virus A monovalent vaccine in children with cancer

PURPOSE

This study investigated the immune response to 2009 pandemic H1N1 influenza monovalent vaccine in children with cancer receiving chemotherapy.

METHODS

We enrolled 25 pediatric patients. Ten patients younger than 10 years old received two vaccinations and the remaining 15 patients older than 10 years old received one. We checked hemagglutination-inhibition (HAI) antibody titers in sera of patients before and 3-4 weeks after vaccination. Seroprotective titer was defined as HAI antibody titer ≥ 40 and seroresponse as ≥ 4-fold increase in HAI antibody titers after vaccination.

RESULTS

The pre- and post-vaccination seroprotective rates were 52% and 72% (P = 0.24). Sixteen (64%) patients were possibly exposed to 2009 pandemic H1N1 influenza previously, and there was significant association between possible exposure and pre-vaccination seroprotective rate (P = 0.03). Post-vaccination seroresponse rate was 32%, and seroresponse was greater in patients without pre-vaccination seroprotective titer than those with pre-vaccination seroprotective titer (50% vs. 15%, P = 0.07). Children with lymphocyte counts above 1,500/µl during vaccination period had better seroresponse than those with lymphocyte counts below 1,500/µl (P = 0.008). Post-vaccination geometric mean titer (GMT) significantly increased in patients younger than 10 years receiving two vaccinations (pre- and post-vaccination GMT were 21.4 and 60.6, respectively; P = 0.025).

CONCLUSIONS

Monovalent vaccine for the 2009 pandemic H1N1 influenza A was found to be partially immunogenic in children with cancer, as evidenced by 32% of seroresponse rate. Immune response can be improved with vaccinations administered to patients whose absolute lymphocyte counts returned to a level of 1,500/µl or higher.

Vaccines for prophylaxis of viral infections in patients with hematological malignancies

BACKGROUND

Viral infections cause significant morbidity and mortality in patients with hematological malignancies. It remains uncertain whether viral vaccinations in these patients are supported by good evidence.

OBJECTIVES

We aimed to determine the effectiveness and safety of viral vaccines in patients with hematological malignancies.

SEARCH STRATEGY

We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL (June 2010), reference lists of relevant papers, abstracts from scientific meetings and contacted vaccine manufacturers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) evaluating viral vaccines in patients with hematological malignancies were included.

DATA COLLECTION AND ANALYSIS

Relative risk (RR) was used for binary data and mean difference (MD) for continuous data. Primary outcome was incidence of infection. Secondary outcomes were mortality, incidence of complications and severe viral infection, hospitalization, immune response and adverse effects. Fixed-effect model was used in meta-analyses.

MAIN RESULTS

Eight RCTs were included, with 305 patients in the intervention groups and 288 in the control groups. They evaluated heat-inactivated varicella zoster virus (VZV) vaccine (two trials), influenza vaccines (five trials) and inactivated poliovirus vaccine (IPV) (one trial). Seven trials had high and one trial had moderate risk of bias.VZV vaccine might reduce herpes zoster compared to no vaccine (RR 0.54, 95% CI 0.3 to 1.0, P=0.05), but not statistically significant. Vaccination also demonstrated efficacy in immune response but frequently caused local adverse effects. One trial reported severity score of zoster, which favored vaccination (MD 2.6, 95% CI 0.94 to 4.26, P=0.002).Two RCTs compared inactivated influenza vaccine with no vaccine and reported lower risk of lower respiratory infections (RR 0.39, 95% CI 0.19 to 0.78, P=0.008) and hospitalization (RR 0.17, 95% CI 0.09 to 0.31, P<0.00001) in vaccine recipients. However, vaccine recipients more frequently experienced irritability and local adverse effects. There was no significant difference in seroconversion between one and two doses of influenza vaccine (one trial), or between recombinant and standard influenza vaccine (one trial), or influenza vaccine given with or without re-induction chemotherapy (one trial).The IPV trial comparing vaccination starting at 6 versus 18 months after stem cell transplant (SCT) found no significant difference in seroconversion.

AUTHORS' CONCLUSIONS

Inactivated VZV vaccine might reduce zoster severity in adult SCT recipients. Inactivated influenza vaccine might reduce respiratory infections and hospitalization in adults with multiple myeloma or children with leukemia or lymphoma. However, the quality of evidence is low. Local adverse effects occur frequently. Further high-quality RCTs are needed.

Influenza vaccination for terminally ill cancer patients receiving palliative care: a preliminary report

CONTEXT

Cancer patients have impaired humoral and cellular immunity, and are more susceptible to infections; their immunological response is expected to be less effective than that of healthy people.

OBJECTIVES

To assess the immune response to influenza vaccine in terminally ill cancer patients in a home palliative care unit.

METHODS

During the fall of 2000-2001, 2005-2006, and 2006-2007, terminally ill cancer patients treated by our home palliative care unit were vaccinated against influenza with Vaxigrip(®). Blood samples were taken before and four weeks after vaccination. Influenza immunological response parameters accepted in the literature were calculated.

RESULTS

Eighteen terminal cancer patients were vaccinated against influenza strains predicted for that year; 13 completed the study. The other five patients died within less than a month from the time of vaccination. The serum protection rate increased from 15.4% before to 61.5% after vaccination, and the serum response rate was 53.8% for all the three strains of vaccination. Mean-fold increase was 24.9 for influenza A-H1N1, 15.4 for influenza A-H3N2, and 2.8 for influenza B. Geometric mean titer was increased for influenza A-H3N2 from 8.3 before vaccination to 159.4 after vaccination; for influenza A-H1N1 from 5.2 to 124.3, and for influenza B from 5.7 to 44.6.

CONCLUSION

The results indicate that influenza vaccination is probably effective and can be offered to terminally ill cancer patients with a life expectancy of about three months in a home care palliative care unit.

Utility of Influenza Vaccination for Oncology Patients

Every fall and winter, patients with cancer and their families ask oncologists whether they should be vaccinated for influenza. This season, with escalating concerns regarding the novel H1N1 influenza virus and its recently approved vaccine, this question has become more frequent and increasingly urgent. The purpose of this article is to review evidence related to the ability of patients with cancer to mount protective immunological responses to influenza vaccination. The literature on immunogenicity in pediatric and adult patients, those with solid tumors and hematologic malignancies, untreated and actively treated patients, and patients receiving biologic agents is summarized and reviewed. In addition, we report on potential strategies to improve the efficacy of influenza vaccination in patients with cancer, such as the timing of vaccination, use of more than a one-shot series, increasing the antigen dose, and the use of adjuvant therapies. We conclude that there is evidence that patients with cancer receiving chemotherapy are able to respond to influenza vaccination, and because this intervention is safe, inexpensive, and widely available, vaccination for seasonal influenza and the novel H1N1 strain is indicated.

Influenza vaccination in children being treated with chemotherapy for cancer

BACKGROUND

Influenza infection is a potential cause of severe morbidity in children with cancer, therefore vaccination against influenza is recommended. However, there are conflicting data concerning the immune response to influenza vaccination in children with cancer and the value of vaccination remains unclear.

OBJECTIVES

1. To assess the efficacy of influenza vaccination in stimulating immunological response in children with cancer during chemotherapy, compared to control groups. 2. To assess the efficacy of influenza vaccination in preventing confirmed influenza and influenza-like illness and/or stimulating immunological response in children with cancer treated with chemotherapy, compared to placebo, no intervention or different dosage schedules. 3. To determine the adverse effects associated with influenza vaccination in children with cancer.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE (1966 to 2007) and EMBASE (1980 to 2007) up to February 2007. We also searched reference lists of relevant articles and conference proceedings of ICAAC, IDSA, MASCC and SIOP.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) and controlled clinical trials (CCTs) in which the serologic response to influenza vaccination of children with cancer was compared to other control groups. We also considered RCTs and CCTs comparing the effects of influenza vaccination on clinical response and/or immunological response in children with cancer, with placebo, no intervention or different dosage schedules.

DATA COLLECTION AND ANALYSIS

Two independent authors assessed the methodological quality of included studies and extracted data.

MAIN RESULTS

We included 1 RCT and 8 CCTs ( total number of participants=708). None of the included studies reported on clinical outcome. All included studies reported on influenza immunity and adverse reactions to vaccination. In five studies, immune responses to influenza vaccine were compared in 272 children on chemotherapy with 166 children not on chemotherapy. In three studies, responses to influenza vaccine were assessed in 204 children on chemotherapy compared with responses in 112 healthy children. The measures used to assess immune responses were: a four-fold rise in antibody titre after vaccination, development of haemagglutination inhibition (HI) titre > 32, and pre- and post-vaccination geometric mean titres (GMT). Immune responses in children receiving chemotherapy were consistently weaker (four-fold rise of 25% to 52%) than in those children who had completed chemotherapy (50% to 86%) and in healthy children (71% to 89%). Concerning adverse effects, 359 paediatric oncology patients received influenza vaccine and the side effects described were mild local reactions and low grade fever. No life-threatening or persistent adverse effects were reported.

AUTHORS' CONCLUSIONS

Paediatric oncology patients receiving chemotherapy are able to generate an immune response to the influenza vaccine, but it remains unclear whether this immune response protects them from influenza infection or its complications. We are awaiting results from well-designed RCTs addressing the clinical benefit of influenza vaccination in these patients.

Immunogenicity of influenza vaccination in patients with non-Hodgkin lymphoma

PURPOSE

The purpose of this study was to assess humoral response to influenza vaccine in patients (pts) with non-Hodgkin lymphoma (NHL) as compared to healthy subjects (ctrl).

PATIENTS AND METHODS

In two epidemic seasons, 2003/2004 and 2004/2005, 163 pts and 92 ctrl were vaccinated. Antibody titers to hemagglutinin (HA) and neuraminidase (NA) were measured in serum samples collected before vaccination, and 1 and 6 months apart. Changes in antibody titers were assessed by comparing geometric mean titers (GMT), mean fold increases (MFI), and seroprotection and seroresponse rates to baseline values.

RESULTS

Pts vaccinated in 2003/2004 had, after 1 month, increase in GMT by a factor of 8.64-26.60 for antihemagglutinin antibodies (HI) and 6.93-12.66 for antineuraminidase antibodies (NI), as compared to factor of 9.12-24.41 for HI and 4.83-10.31 for NI in ctrl. At 1 month after vaccination, seroprotection and seroresponse rates were similar in both groups, ranging from 68.42 to 84.21% and 71.93 to 94.74% in NHL, and 66.67-82.22% and 62.22-86.67% in ctrl, respectively. Pts vaccinated in 2004/2005 had increase in the GMT by a factor of 38.76-41.49 for HI and 26.59-30.31 for NI, as compared to factor of 81.19-104.32 for HI and 52.16-54.52 for NI in ctrl. Seroprotection and seroresponse rates were lower in the former group, ranging from 62.11 to 65.26% and 74.47 to 77.66%, respectively. In both seasons, pts achieved titres of antibodies greater than the protective threshold, irrespective of the previous chemotherapy administration.

CONCLUSIONS

The results indicate that influenza vaccination induces sufficient immune response in pts with NHL, irrespective of previous chemotherapy.

Evaluation of vaccine dosing in patients with solid tumors receiving myelosuppressive chemotherapy

OBJECTIVE

To provide oncology healthcare providers with information on current vaccine recommendations and discuss the proper timing of vaccination in relation to chemotherapy, to allow for an adequate, protective antibody response.

DATA SOURCES

In this review, we have attempted to include all available literature as well as the current recommendations. The National Library of Medicine, PubMed online database was searched using the keywords: chemotherapy, influenza, vaccine, cancer, immunosuppression. In addition, the Center for Disease Control (CDC) guidelines were reviewed and incorporated into the recommendations.

DATA SYNTHESIS

There were several limitations to the literature available. To date, most of the literature was completed in the 1970s and 1980s, and definitions of protective immunity regarding influenza vaccines have changed over time, as well as improved study design. These studies have also been completed in a variety of disease states, hence, it is difficult to make comparisons between trials. The recommendations in this review are consistent with the current CDC Guidelines and, until further clinical trials are carried out, are the most conservative recommendations in favor of patient safety, health care costs, and resource utilization.

CONCLUSION

Patients on cancer chemotherapy should receive vaccination at least 2 weeks before initiation of treatment. Providers should avoid administering vaccination during chemotherapy or active radiation treatment because of suboptimal responses to vaccines. Active immunization has been shown to confer protective immunity to several infections in cancer patients at similar rates to healthy individuals.

Efficacy of the influenza vaccine in patients with malignant lymphoma

BACKGROUND

The benefits and efficacy of the influenza vaccine have been controversial and have had mixed reviews in the recent literature. Immunosuppressed patients and those receiving chemotherapy are particularly at risk for infectious complications and are therefore given high priority to receiving prophylactic vaccines.

METHOD

We administered the influenza vaccine to 29 patients with malignant lymphoma who were receiving chemotherapy or had recently completed therapy during the flu season of 2003-2004. An aged-matched control group received the same vaccine during the same period. The ability of both groups to mount a protective titer of antibodies to the antigens in the vaccine was measured.

RESULTS

Three of 29 patients (10%) in the lymphoma group were able to mount a 4-fold titer to at least one of the influenza A antigens. One patient developed a protective titer to both influenza A and B antigens and 3 of 29 responded to the influenza B antigen. In the control group 13 of 29 (45%) responded to an influenza A antigen and 14 of 29 (48%) had a 4-fold response to the B antigen. Seven of 29 controls (24%) had a 4-fold increase in their titers to both the A and B antigens.

CONCLUSIONS

This study confirmed the low incidence of response or efficacy to the influenza vaccine reported in previous studies. Only a small percentage (10%) of immunosuppressed patients with malignant lymphoma responded with a 4-fold increase in their antibody titer to the major antigens of the 2003 influenza vaccine. Most interestingly, less than 50% of the aged-matched control population studied responded with a 4-fold increase in their antibody titer. Additional studies are needed to determine methods for improving the efficacy of the vaccine and the effectiveness of the influenza vaccination program in preventing influenza infections in the United States.

Immune responses to influenza immunization in children receiving maintenance chemotherapy for acute lymphoblastic leukemia

PURPOSE

To compare the immune responses to influenza vaccine in children with acute lymphoblastic leukemia (ALL) receiving maintenance chemotherapy with those in healthy children.

METHODS

Hemagglutinin-inhibition (HAI) antibody titers were determined before and after influenza vaccination in children with ALL and healthy controls. Immune responses were measured as geometric mean titers (GMT) and 4-fold rises in HAI titers.

RESULTS

Although post-immunization GMT were lower in children with ALL compared to healthy children for the H1N1 antigen (P<0.001), the H3N2 antigen (P=0.03), and for the influenza B antigen (P=0.003), at least 60% of children with ALL had at least a 4-fold rise in HAI titers to each of the influenza antigens.

CONCLUSIONS

While the GMT after trivalent influenza immunization in children with ALL were significantly lower than those seen in healthy children, the majority of children with ALL had 4-fold rises in HAI titers. Children receiving maintenance chemotherapy for ALL should receive yearly influenza vaccine.

Vaccination against infections in chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is a well-defined mature B-cell neoplasm associated with increased susceptibility to infections. Two major options in prevention of infections in CLL, intravenous gammaglobulin treatment and antimicrobial chemoprophylaxis, have not resulted in satisfactory outcome. A third strategy, antimicrobial vaccination, is the topic of this minireview. We collected articles and their references concerning CLL vaccination from the Medline database starting from 1966 and thirteen relevant studies were found. Plain bacterial polysaccharide vaccines would seem to be ineffective in antibody formation in patients with CLL. However, protein and conjugate vaccines appear to be more immunogenic and their responses may be further enhanced with ranitidine adjuvant treatment. New well-designed investigations are needed to develop appropriate vaccination strategies and evaluate vaccination efficacy in infection morbidity and mortality in CLL.

Influenza vaccine in chronic lymphoproliferative disorders and multiple myeloma

OBJECTIVE

Vaccination against influenza in patients with chronic lymphoproliferative disorders (CLPD) and multiple myeloma (MM) is still a matter of clinical uncertainty. The aim of this study was to determine the safety, immunogenicity and clinical response to a commercially available vaccine against influenza in a group of such patients.

METHODS

Thirty-four patients with CLPD and MM and 34 immunologically normal subjects were vaccinated with the same vaccine against influenza. Patients were observed during the epidemic season from October 1999 to April 2000, and monitored for side-effects of the vaccine, seroprotection and seroconversion after vaccination. The prevaccination level of immunoglobulins was also determined. Occurrence of influenza episodes was demonstrated with the positive isolation of a viral strain from a pharyngeal swab.

RESULTS

No patient had untoward reactions to the vaccine used. Seroconversion and seroprotection were up to the standard established by the European Agency for the Evaluation of Medicinal Products. Only one patient developed influenza during follow-up.

CONCLUSIONS

Influenza vaccine is effective and well tolerated in patients with CLPD and MM. No contraindications exist for its use, and it should become a routine practice, in order to prevent serious complications during the influenza epidemic season.

Influenza vaccination in elderly patients with advanced colorectal cancer

PURPOSE

To examine influenza vaccination use in patients undergoing chemotherapy for advanced cancer.

METHODS

All Medicare patients treated for stage IV colorectal cancer between 1993 and 1998 while living in one of the regions monitored by the Survival, Epidemiology, and End Results Program who were alive in the fall months and who survived at least 4 months with their cancer were considered eligible to have received vaccination. Their medical bills were analyzed to determine receipt of influenza vaccination and subsequent outcomes.

RESULTS

Eligibility criteria were met by 1,225 patients who were undergoing chemotherapy during 1,577 person-years of observation. Overall, 39.7% of patients received influenza vaccination, increasing from 26% in 1993 to 43% in 1998. When vaccination was administered, it was provided by primary care physicians 68% of the time. Vaccinated patients were more likely to be white, of higher socioeconomic status, and to have more comorbidity. Fewer diagnoses of influenza and pneumonia infections were made in vaccinated patients while undergoing treatment. Those patients who were immunized also had fewer chemotherapy interruptions and were more likely to survive through to the beginning of the next fall (hazard ratio, 0.88; 95% confidence interval, 0.77 to 0.99). There was a trend toward decreased resource use among immunized patients.

CONCLUSION

This study observed outcomes associated with influenza vaccination that are similar to those reported for patients without cancer. However, rates of immunization are relatively low, and disparities exist for vulnerable populations. As part of delivering high-quality care, oncologists should promote influenza vaccination for their patients who are undergoing treatment for advanced cancer.

Influenza immunization practices among pediatric oncologists

PURPOSE

To describe the opinions of pediatric oncologists regarding the use of influenza vaccine in children with cancer and to identify factors that influence practitioners' recommendations about influenza vaccine.

MATERIALS AND METHODS

A survey was sent to members of the Children's Oncology Group to inquire about their clinical experience and practice setting, opinions regarding the use of the influenza vaccine in children with cancer, and factors that influence their recommendations.

RESULTS

Of 803 pediatric oncologists identified, 434 (54%) responded. Depending on the type of tumor, 65% to 69% of pediatric oncologists indicated that they routinely recommend influenza vaccine for children being treated for cancer. Respondents were much more likely to recommend influenza vaccine for children with various types of cancer if they indicated that: 1) their practice has guidelines regarding the use of influenza vaccine (odds ratios ranging from 7.2 to 11.7); 2) influenza infection is very significant (odds ratios ranging from 1.4 to 3.7); and 3) influenza vaccine is effective (odds ratios ranging from 7.2 to 14.9).

CONCLUSIONS

The majority of pediatric oncologists routinely recommend influenza vaccine for children being treated for cancer; however, a significant number of pediatric oncologists do not. Clarification of the benefit of influenza vaccine for children with cancer and the institution of practice guidelines may increase the use of the influenza vaccine among pediatric oncologists.

Immunization recommendations for adults with cancer

OBJECTIVE

To review the published literature on immunizing nonbone marrow transplant adult cancer patients, summarize the findings, and make recommendations for the use of vaccines in this population.

DATA SOURCE

A search of MEDLINE and CancerLit was conducted (1966-June 2001) to find English-language clinical studies and review articles pertaining to immunization, vaccines, and cancer in humans. Recommendations of the Advisory Committee on Immunization Practices were used extensively. References of each identified article were subsequently reviewed for additional relevant articles.

STUDY SELECTION AND DATA EXTRACTION

Representative epidemiologic reports, clinical trials, and recommendations of expert panels are summarized in this report. Relevant information was selected to describe the epidemiology of vaccine-preventable diseases, efficacy of the vaccines, and recommendations specific to adults with cancer.

DATA SYNTHESIS

In general, adults with cancer are at least at the same risk of infection with vaccine-preventable diseases as are healthy populations. Because of their compromised immune function, many patients who have undergone cancer treatment are specifically at increased risk of morbidity and mortality associated with measles and varicella infections. Asplenic patients with lymphoma are at increased risk of fulminant bacterial infections. Influenza infection is associated with significant morbidity in cancer patients. Although the protection conferred by immunization is lower in immunosuppressed patients with cancer, immunization with inactivated vaccines is indicated. Live vaccines should not be used except in very rare instances.

CONCLUSIONS

Immunization of adults with cancer is a critical component of their care. Although additional research is necessary, following established recommendations may protect individuals with malignancies from significant morbidity and mortality associated with vaccine-preventable diseases.

Humoral immune response to influenza vaccination in patients from high risk groups

Influenza is one of the most common respiratory diseases. Infections caused by this virus may be very serious and can lead to severe complications. So far, the most effective method of protection against influenza is annual vaccination. The Advisory Committee on Immunisation Practices recommends vaccination against influenza for some groups of people. Unfortunately, in spite of these clear indications, a large number of patients are not vaccinated. This article reviews the current scientific literature on immunological response to influenza vaccination in patients who are at especially high risk for serious post-influenza complications and for whom immunisation against this virus is strongly recommended. Results of studies carried out in Poland and other countries in elderly people, in patients with pulmonary diseases, renal diseases, diabetes mellitus, cancer and haemophilia, and in those with HIV infection are presented. In this review, we focus on the immune response to haemagglutinin. There are some discrepancies between the results of studies carried out by different authors in high risk groups of patients. Some investigations indicated poorer humoral response to influenza vaccine in these groups, while others showed responses comparable to those in healthy individuals. These differences may be explained by differences in types and stages of the chronic diseases, in the treatment and composition of influenza vaccines, and also patients' ages, vaccination history and prevaccination antibody titres. Influenza vaccines are well tolerated in high risk patients, and all adverse reactions are generally mild and similar to those observed in healthy people. Although, in some cases, immunological responses to influenza vaccination measured in the whole study group were poor, there were some individual patients who, after vaccination, developed antihaemaglutinin antibody titres which are considered to give protection against the infection or contribute to a milder course of the disease.

Use of licensed vaccines for active immunization of the immunocompromised host

The latter part of the 20th century has witnessed an unprecedented rise in the number of individuals with impaired immunity. This is primarily attributable to the increased development and use of antineoplastic therapy for malignancies, organ and bone marrow transplantation, and the AIDS epidemic. Individuals with impaired immunity are often at increased risk for infections, and they can experience more severe and complicated courses of infection. The lack of therapy for a variety of viruses and the rise in antimicrobial resistance of many pathogens have focused attention on vaccination to prevent infectious diseases. The efficacy of most licensed vaccines has been established in immunocompetent hosts. However, there is also considerable experience with most vaccines in those with impaired immunity. We reviewed the use of licensed live, inactivated, and polysaccharide vaccines in this group, and several themes emerged: (i) most vaccines are less immunogenic in those with impaired immunity than in normal individuals; (ii) live vaccines are generally contraindicated in this group; and (iii) the efficacy of many commonly used vaccines has not been established in people with impaired immunity. This review suggests that for most vaccines there are little or no efficacy data in those with impaired immunity but their use in this patient group is generally safe.

Antibody response to a two-dose influenza vaccine regimen in adult lymphoma patients on chemotherapy

A study was conducted to determine if a two-dose regimen of influenza vaccine would enhance the immunologic response of 41 patients with lymphoma receiving chemotherapy. Hemagglutinin-inhibiting antibody responses to influenza A/H1N1, A/H3N2 and B virus occurred in 32%, 24% and 20% of patients following one dose, and in 49%, 41% and 46% of patients following two doses, respectively. Responses to one or more vaccine components occurred in 42% of patients after one dose and in 71% after two doses. Fifty percent of the patients who did not respond after one dose responded after two doses. A two-dose regimen of influenza immunization may significantly enhance the response rate of cancer patients receiving chemotherapy.

Influenza vaccination in the elderly: improved antibody response with Imuthiol (Na diethyldithiocarbamate) adjuvant therapy

To improve influenza vaccine efficacy in hospitalized elderly, we compared the evolution of antibody level after vaccination in three patient groups. A sample of apparently primo vaccinated elderly were randomized to receive either Imuthiol (Na diethyldithiocarbamate: group 1) or a placebo (group P). They were compared to patients who had been vaccinated annually for several years (group C). All patients were immunized in the same week. Antibody responses increase within 15 days to reach a plateau in group P and C, while they continue to increase in the Imuthiol treated group, reaching higher antibody levels 30 days after vaccination. This higher antibody rise in group I is essentially due to higher antibody responses in patients with initially low antibody levels and who exhibited at least a four-fold antibody rise. This effect of Imuthiol on influenza antibody responses was observed in spite of a lower nutritional status in this group, a condition that induces lower antibody responses. The higher antibody responses observed in the Imuthiol treated group allow longer protection against influenza.

Prevention and control of influenza. Role of vaccine

A major component in the prevention and control of influenza should be the use of killed influenza vaccines. These vaccines became possible after the first discovery of human strains of influenza virus in the 1930s. The ensuing decades have seen marked improvement in the available inactivated vaccines. Current vaccines have excellent reliability and assured potency, and they contain the proper antigens to match the frequent changes in circulating influenza viruses. Killed vaccines work by inducing serum antibodies against the hemagglutinin and neuraminidase of the vaccine strains, with sufficient antibodies ensuring protection against infection. The antibody responses to current vaccines appear to be adequate in all age groups. Although antibody responses are depressed in patients receiving chemotherapy or immunosuppressants, current vaccines do provide protection for most populations. Vaccines prevent the manifestations of disease by about 30 to 70 percent in all populations, and they reduce deaths in high-risk individuals by about 60 to 87 percent. Local adverse reactions to vaccine are quite common, but not severe. Fever, also somewhat common, usually does not last beyond 48 hours. Neurologic complications have not been observed since the use of the swine influenza vaccine of 1976. Killed vaccines should be given annually in the fall, but they can be given up to and during an outbreak. Target groups for vaccines have been defined by the Centers for Disease Control. In recent years, these groups have included physicians and nurses who give care to patients at risk for complications of influenza.

Recent trends in incidence and mortality rates for leukemias, and in survival rates for childhood acute lymphocytic leukemia, in Upstate New York

Analysis of mortality rates for all childhood (age less than 20 years) leukemias in upstate New York showed declines between 1969-1971 and 1978-1980 for ages 0-4 and 5-9 years, while data from a population-based cancer registry for a population of about 10.5 million indicated no decline in incidence rates. Survival rates were examined for 552 children diagnosed with acute lymphocytic leukemia (ALL) in 1973-1980 at less than 15 years of age. There was some evidence for improvement in survival rates over these years of diagnosis, especially among children diagnosed at ages 1-4 and 10-14 years. Hazard rates increased among cases (especially males) diagnosed in 1979 and 1980, however, and this finding requires confirmation from other studies; the possible effect of influenza epidemics also should be explored. Only one confirmed second primary cancer, a rhabdomyosarcoma of the eye, was ascertained (as of the end of 1983), but longer follow-up is needed on children with ALL.

Antibody response to pneumococcal vaccine in patients with solid tumors and lymphomas

Ninety patients with solid tumors or lymphomas were immunized with a polyvalent pneumococcal vaccine. Pre- and postimmunization antibody titers were determined by radioimmunoassay. Treated patients with lymphoma had poor antibody response whether on or off chemotherapy. Patient with chronic lymphocytic leukemia had the lowest antibody titers of all patients groups. Patients with solid tumors had antibody responses which were similar to those of the control population. Those patients who received sequential chemotherapy and immunization had a tendency for higher postimmunization titers than those patients who received simultaneous chemotherapy and immunization, but the difference was not significant. This study suggests that patients with solid tumors would be expected to benefit from pneumococcal immunization, whereas patients with lymphoma immunized after receiving treatment initially would not be expected to develop protective antibody levels. Recovery of antibody formation in patients with non-Hodgkin lymphoma, which may occur in patients with Hodgkin disease, remains to be determined.