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Arya S, Shahid Z. Overview of infectious complications among CAR T- cell therapy recipients. Front Oncol 2024; 14:1398078. [PMID: 39026972 PMCID: PMC11255439 DOI: 10.3389/fonc.2024.1398078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/04/2024] [Indexed: 07/20/2024] Open
Abstract
Chimeric antigen receptor-modified T cell (CAR T-cell) therapy has revolutionized the management of hematological malignancies. In addition to impressive malignancy-related outcomes, CAR T-cell therapy has significant toxicity-related adverse events, including cytokine release syndrome (CRS), immune effector cell associated neurotoxicity syndrome (ICANS), immune effector cell-associated hematotoxicity (ICAHT), and opportunistic infections. Different CAR T-cell targets have different epidemiology and risk factors for infection, and these targets result in different long-term immunodeficiency states due to their distinct on-target and off- tumor effects. These effects are exacerbated by the use of multimodal immunosuppression in the management of CRS and ICANS. The most effective course of action for managing infectious complications involves determining screening, prophylactic, and monitoring strategies and understanding the role of immunoglobulin replacement and re-vaccination strategies. This involves considering the nature of prior immunomodulating therapies, underlying malignancy, the CAR T-cell target, and the development and management of related adverse events. In conclusion, we now have an increasing understanding of infection management for CAR T-cell recipients. As additional effector cells and CAR T-cell targets become available, infection management strategies will continue to evolve.
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Affiliation(s)
- Swarn Arya
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Zainab Shahid
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Weill Cornell School of Medicine, New York, NY, United States
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2
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Neemann KA, Sato AI. Vaccinations in children with hematologic malignancies and those receiving hematopoietic stem cell transplants or cellular therapies. Transpl Infect Dis 2023; 25 Suppl 1:e14100. [PMID: 37436808 DOI: 10.1111/tid.14100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/23/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023]
Abstract
Children who are immune compromised are uniquely threatened by a higher risk of infections, including vaccine-preventable diseases (VPDs). Children who undergo chemotherapy or cellular therapies may not have preexisting immunity to VPDs at the time of their treatment including not yet receiving their primary vaccine series, and additionally they have higher risk of exposures (e.g., due to family structures, daycare and school setting) with decreased capacity to protect themselves using nonpharmaceutic measures (e.g., masking). In the past, efforts to revaccinate these children have often been delayed or incomplete. Treatment with chemotherapy, stem cell transplants, and/or cellular therapies impair the ability of the immune system to mount a robust vaccine response. Ideally, protection would be provided as soon as both safe and effective, which will vary by vaccine type (e.g., replicating versus nonreplicating; conjugated versus polysaccharide). While a single approach revaccination schedule following these therapies would be convenient for providers, it would not account for patient specific factors that influence the timing of immune reconstitution (IR). Evidence suggests that many of these children would mount a meaningful vaccine response as early as 3 months following completion of treatment. Here within, we provide updated guidance on how to approach vaccination both during and following completion of these therapies.
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Affiliation(s)
- Kari A Neemann
- Division of Infectious Diseases, Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Children's Hospital & Medical Center, Omaha, Nebraska, USA
| | - Alice I Sato
- Division of Infectious Diseases, Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Children's Hospital & Medical Center, Omaha, Nebraska, USA
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3
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SARS-CoV-2 vaccine safety and immunogenicity in patients with hematologic malignancies, transplantation, and cellular therapies. Blood Rev 2022; 56:100984. [PMID: 35752546 PMCID: PMC9188822 DOI: 10.1016/j.blre.2022.100984] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/03/2022] [Accepted: 06/07/2022] [Indexed: 11/23/2022]
Abstract
Individuals with hematological malignancies and hematopoietic stem cell transplant (HCT) recipients are immunologically heterogenous groups with varying degrees of immunosuppression at increased risk of severe disease and mortality from SARS-CoV-2 infection. SARS-CoV-2 vaccines are key interventions to preventing severe COVID-19 and its complications. While these individuals were excluded from initial vaccine trials, there is now a growing body of acceptable safety and immunogenicity data among these individuals. A consistent signal for new or worsening graft versus host disease in allogeneic HCT recipients has not been demonstrated post-vaccination. Immunogenicity in these populations is variable depending on disease and treatment factors. However, serological responses may not accurately reflect vaccine protection as correlates of protection within these populations are not yet established. Large-scale studies powered to identify rare serious events, resolve differences in vaccine responses between different vaccination strategies, and identify immune correlates of protection within these populations are needed.
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Takeshita K, Ishiwada N, Takeuchi N, Ohkusu M, Ohata M, Hino M, Hishiki H, Takeda Y, Sakaida E, Takahashi Y, Shimojo N, Hamada H. Immunogenicity and safety of routine 13-valent pneumococcal conjugate vaccination outside recommended age range in patients with hematological malignancies and solid tumors. Vaccine 2022; 40:1238-1245. [DOI: 10.1016/j.vaccine.2022.01.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/13/2022] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
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Froneman C, Kelleher P, José RJ. Pneumococcal Vaccination in Immunocompromised Hosts: An Update. Vaccines (Basel) 2021; 9:536. [PMID: 34063785 PMCID: PMC8223771 DOI: 10.3390/vaccines9060536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 01/04/2023] Open
Abstract
Infections with the pathogen, Streptococcus pneumoniae, are a common cause of morbidity and mortality worldwide. It particularly affects those at the extremes of age and immunocompromised individuals. Preventing pneumococcal disease is paramount in at risk individuals, and pneumococcal vaccination should be offered. Here, we discuss the role of pneumococcal vaccination in specific groups of immunocompromised hosts.
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Affiliation(s)
- Claire Froneman
- Department of Respiratory Medicine, Royal Brompton Hospital, London SW3 6NP, UK; (C.F.); (P.K.)
| | - Peter Kelleher
- Department of Respiratory Medicine, Royal Brompton Hospital, London SW3 6NP, UK; (C.F.); (P.K.)
- Department of Infectious Disease, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Ricardo J. José
- Department of Respiratory Medicine, Royal Brompton Hospital, London SW3 6NP, UK; (C.F.); (P.K.)
- Centre for Inflammation and Tissue Repair, UCL, London WC1E 6BT, UK
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How I prevent infections in patients receiving CD19-targeted chimeric antigen receptor T cells for B-cell malignancies. Blood 2021; 136:925-935. [PMID: 32582924 DOI: 10.1182/blood.2019004000] [Citation(s) in RCA: 161] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/21/2020] [Indexed: 02/06/2023] Open
Abstract
Adoptive immunotherapy using B-cell-targeted chimeric antigen receptor (CAR)-modified T cells to treat hematologic malignancies is transforming cancer care for patients with refractory or relapsed diseases. Recent and anticipated regulatory approval for products targeting acute lymphoblastic leukemia, lymphomas, and multiple myeloma have led to global implementation of these novel treatments. The rapidity of commercial utilization of CAR-T-cell therapy has created a largely unexplored gap in patient supportive-care approaches. Such approaches are critical in these complex patients given their high net state of immunosuppression prior to CAR-T-cell infusion coupled with unique acute and persistent insults to their immune function after CAR-T-cell infusion. In this "How I Treat" article, we focus on key questions that arise during 3 phases of management for patients receiving CD19-targeted CAR-T cells: pre CAR-T-cell infusion, immediate post CAR-T-cell infusion, and long-term follow-up. A longitudinal patient case is presented for each phase to highlight fundamental issues including infectious diseases screening, antimicrobial prophylaxis, immunoglobulin supplementation, risk factors for infection, and vaccination. We hope this discussion will provide a framework for institutions and health care providers to formulate their own approach to preventing infections in light of the paucity of data specific to this treatment modality.
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Merz AM, Merz M, Zhang Y, Stecklein K, Pleskow J, Chen GL, Buck DA, Mohammadpour H, Herr MM, Elshoury A, Hillengass J, McCarthy PL, Hahn T. Serological Response to Vaccination after Autologous Transplantation for Multiple Myeloma Is Associated with Improved Progression-Free and Overall Survival. Transplant Cell Ther 2021; 27:245.e1-245.e8. [DOI: 10.1016/j.jtct.2020.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/29/2020] [Accepted: 11/01/2020] [Indexed: 11/29/2022]
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Rieger CT, Liss B, Mellinghoff S, Buchheidt D, Cornely OA, Egerer G, Heinz WJ, Hentrich M, Maschmeyer G, Mayer K, Sandherr M, Silling G, Ullmann A, Vehreschild MJGT, von Lilienfeld-Toal M, Wolf HH, Lehners N. Anti-infective vaccination strategies in patients with hematologic malignancies or solid tumors-Guideline of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO). Ann Oncol 2019; 29:1354-1365. [PMID: 29688266 PMCID: PMC6005139 DOI: 10.1093/annonc/mdy117] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Infectious complications are a significant cause of morbidity and mortality in patients with malignancies specifically when receiving anticancer treatments. Prevention of infection through vaccines is an important aspect of clinical care of cancer patients. Immunocompromising effects of the underlying disease as well as of antineoplastic therapies need to be considered when devising vaccination strategies. This guideline provides clinical recommendations on vaccine use in cancer patients including autologous stem cell transplant recipients, while allogeneic stem cell transplantation is subject of a separate guideline. The document was prepared by the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO) by reviewing currently available data and applying evidence-based medicine criteria.
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Affiliation(s)
- C T Rieger
- Hematology and Oncology Germering, Lehrpraxis der Ludwig-Maximilians-Universität, University of Munich, Munich.
| | - B Liss
- Department of Internal Medicine, Helios University Hospital Wuppertal, Wuppertal
| | - S Mellinghoff
- Department I of Internal Medicine, University Hospital Cologne, Cologne; CECAD Cluster of Excellence, University of Cologne, Cologne
| | - D Buchheidt
- Department of Internal Medicine - Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Heidelberg
| | - O A Cornely
- Department I of Internal Medicine, University Hospital Cologne, Cologne; CECAD Cluster of Excellence, University of Cologne, Cologne; Clinical Trials Center Cologne, ZKS Köln, University Hospital of Cologne, Cologne
| | - G Egerer
- Department of Hematology, University Hospital Heidelberg, Heidelberg
| | - W J Heinz
- Department of Internal Medicine II - Hematology and Oncology, University of Würzburg, Würzburg
| | - M Hentrich
- Department of Hematology and Oncology, Rotkreuzklinikum München, Munich
| | - G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam
| | - K Mayer
- Department of Hematology and Oncology, University Hospital Bonn, Bonn
| | | | - G Silling
- Department of Hematology and Oncology, University of Aachen, Aachen
| | - A Ullmann
- Department of Internal Medicine II - Hematology and Oncology, University of Würzburg, Würzburg
| | - M J G T Vehreschild
- Department of Internal Medicine, Helios University Hospital Wuppertal, Wuppertal
| | - M von Lilienfeld-Toal
- Department of Hematology and Oncology, Internal Medicine II, University Hospital Jena, Jena
| | - H H Wolf
- Department of Hematology and Oncology, University Hospital Halle, Halle
| | - N Lehners
- Department of Hematology, University Hospital Heidelberg, Heidelberg; Max-Eder-Group Experimental Therapies for Hematologic Malignancies, German Cancer Research Center (DKFZ), Heidelberg, Germany
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Roberts MB, Bak N, Wee LYA, Chhetri R, Yeung DT, Lewis I, Hiwase DK. Clinical Effectiveness of Conjugate Pneumococcal Vaccination in Hematopoietic Stem Cell Transplantation Recipients. Biol Blood Marrow Transplant 2019; 26:421-427. [PMID: 31627016 DOI: 10.1016/j.bbmt.2019.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/24/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) recipients are vulnerable to invasive pneumococcal disease (IPD), with reported IPD rates ranging from 3.81 to 22.5/1000 HSCT. This IPD risk could relate to immunodeficiency, low vaccination uptake, and poor immunogenicity of pneumococcal polysaccharide vaccine (PPV). Literature comparing the clinical effectiveness of pneumococcal conjugate vaccination (PCV) and PPV after HSCT is limited. In this retrospective analysis of HSCT recipients at our center from 2004 to 2015, we evaluated vaccination uptake and compared IPD rates in patients receiving PPV (pre-2010 group) and PCV (post-2010 group). IPD was determined from microbiological results for all HSCT recipients from January 2004 to June 30, 2019. Eight hundred patients had a total of 842 HSCT events, including autologous HSCT (auto-HSCT; n = 562) and allogeneic HSCT (allo-HSCT; n = 280). More than 90% of the HSCT recipients were enrolled, and >93% of surviving HSCT recipients completed the vaccination protocol. Fifteen IPD episodes occurred in 13 patients between 2004 and June 30, 2019. Thirteen episodes occurred in the pre-2010 group, even though 9 of 13 (69%) serotyped isolates were covered by PPV. Two episodes occurred in the post-2010 group; neither serotype was covered by PCV. Thus, with PCV introduction, IPD rate was significantly reduced from 38.5/1000 unique HSCTs pre-2010 to 4.0/1000 unique HSCTs post-2010 (P < .001). A significant reduction was seen in both auto-HSCTs (from 29.4 to 3.1 /1000 unique auto-HSCTs; P = .011) and allo-HSCTs (from 58.3 to 5.6/1000 unique allo-HSCTs; P = .011). PCV demonstrated superior clinical effectiveness over PPV, highlighting its importance in preventing infectious complications after HSCT. Robust vaccination programs at transplantation centers are needed to optimize vaccination uptake and completion.
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Affiliation(s)
- Matthew B Roberts
- Infectious Diseases Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Narin Bak
- Infectious Diseases Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Li Yan A Wee
- Royal Adelaide Hospital, Adelaide, Australia; Cancer Theme, South Australian Health and Medical Research Institute. Department of Medicine, University of Adelaide, Adelaide, Australia
| | - Rakchha Chhetri
- Royal Adelaide Hospital, Adelaide, Australia; Cancer Theme, South Australian Health and Medical Research Institute. Department of Medicine, University of Adelaide, Adelaide, Australia; School of Medicine, University of Adelaide, Adelaide, Australia
| | - David T Yeung
- Royal Adelaide Hospital, Adelaide, Australia; Cancer Theme, South Australian Health and Medical Research Institute. Department of Medicine, University of Adelaide, Adelaide, Australia; School of Medicine, University of Adelaide, Adelaide, Australia
| | - Ian Lewis
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Devendra K Hiwase
- Royal Adelaide Hospital, Adelaide, Australia; Cancer Theme, South Australian Health and Medical Research Institute. Department of Medicine, University of Adelaide, Adelaide, Australia; School of Medicine, University of Adelaide, Adelaide, Australia.
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10
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Cordonnier C, Einarsdottir S, Cesaro S, Di Blasi R, Mikulska M, Rieger C, de Lavallade H, Gallo G, Lehrnbecher T, Engelhard D, Ljungman P. Vaccination of haemopoietic stem cell transplant recipients: guidelines of the 2017 European Conference on Infections in Leukaemia (ECIL 7). THE LANCET. INFECTIOUS DISEASES 2019; 19:e200-e212. [PMID: 30744963 DOI: 10.1016/s1473-3099(18)30600-5] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/21/2018] [Accepted: 09/18/2018] [Indexed: 12/17/2022]
Abstract
Infection is a main concern after haemopoietic stem cell transplantation (HSCT) and a major cause of transplant-related mortality. Some of these infections are preventable by vaccination. Most HSCT recipients lose their immunity to various pathogens as soon as the first months after transplant, irrespective of the pre-transplant donor or recipient vaccinations. Vaccination with inactivated vaccines is safe after transplantation and is an effective way to reinstate protection from various pathogens (eg, influenza virus and Streptococcus pneumoniae), especially for pathogens whose risk of infection is increased by the transplant procedure. The response to vaccines in patients with transplants is usually lower than that in healthy individuals of the same age during the first months or years after transplant, but it improves over time to become close to normal 2-3 years after the procedure. However, because immunogenic vaccines have been found to induce a response in a substantial proportion of the patients as early as 3 months after transplant, we recommend to start crucial vaccinations with inactivated vaccines from 3 months after transplant, irrespectively of whether the patient has or has not developed graft-versus-host disease (GvHD) or received immunosuppressants. Patients with GvHD have higher risk of infection and are likely to benefit from vaccination. Another challenge is to provide HSCT recipients the same level of vaccine protection as healthy individuals of the same age in a given country. The use of live attenuated vaccines should be limited to specific situations because of the risk of vaccine-induced disease.
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Affiliation(s)
- Catherine Cordonnier
- Haematology Department, Henri Mondor Hospital, Assistance Publique-Hopitaux de Paris, Créteil, France; University Paris-Est Créteil, Créteil, France.
| | - Sigrun Einarsdottir
- Section of Hematology, Department of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, Göteborg, Sweden
| | - Simone Cesaro
- Pediatric Hematology Oncology Unit, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Roberta Di Blasi
- Haematology Department, Henri Mondor Hospital, Assistance Publique-Hopitaux de Paris, Créteil, France
| | - Malgorzata Mikulska
- University of Genoa (DISSAL) and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Christina Rieger
- Department of Hematology Oncology, University of Munich, Germering, Germany
| | - Hugues de Lavallade
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Giuseppe Gallo
- Pediatric Hematology Oncology Unit, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Thomas Lehrnbecher
- Paediatric Haematology and Oncology Department, Hospital for Children and Adolescents, University of Frankfurt, Frankfurt, Germany
| | - Dan Engelhard
- Department of Pediatrics, Hadassah-Hebrew University Medical Center, Ein-Kerem Jerusalem, Israel
| | - Per Ljungman
- Department of Cellular Therapy and Allogeneneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Stockholm, Sweden
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11
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Langedijk AC, van Aalst M, Meek B, van Leeuwen EMM, Zeerleder S, Meijer E, Hazenberg MD, Grobusch MP, Goorhuis A. Long-term pneumococcal vaccine immunogenicity following allogeneic hematopoietic stem cell transplantation. Vaccine 2018; 37:510-515. [PMID: 30502071 DOI: 10.1016/j.vaccine.2018.11.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 11/15/2018] [Accepted: 11/19/2018] [Indexed: 12/24/2022]
Abstract
Infection with Streptococcus pneumoniae is a life-threatening, but vaccine preventable complication in patients with allogeneic hematopoietic stem cell transplantation (allo-HSCT). The international consensus on post allo-HSCT immunization schedules, starting 3-6 months after HSCT, focuses on short-term immunogenicity while long-term immunogenicity is not well characterized. The current Dutch immunization schedule, which starts at 12 months post allo-HSCT, was developed as a result of concerns on the coverage of long-term immunogenicity in international guidelines. We recently encountered two cases of allo-HSCT recipients who developed invasive pneumococcal disease (IPD) despite adequate revaccinations, which led us to question the immunogenicity of pneumococcal vaccinations in this patient group, and whether the currently existing vaccination schedules are appropriate. We included allo-HSCT recipients, vaccinated from one year after transplantation, and tested antibody responses to pneumococcal vaccination. We also performed a systematic review. Antibody concentrations were measured in 42 of 103 (41%) patients, with a response rate of 85% to PCV13 and 62% to PPSV23-unique serotypes. In six relevant studies, protection rates varied between 64 and 98%. Antibody responses in early and late vaccination schedules were similar, but adequate antibody responses were maintained better after late vaccination. Therefore, we propose a vaccination schedule that combines the advantages of early and late vaccination. This new schedule has been introduced since March 2018 in the two academic hospitals in Amsterdam, The Netherlands.
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Affiliation(s)
- Annefleur C Langedijk
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, 1105AZ Amsterdam, the Netherlands
| | - Mariëlle van Aalst
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, 1105AZ Amsterdam, the Netherlands
| | - Bob Meek
- Department of Medical Microbiology and Immunology, St. Antonius Hospital, 3435CM Nieuwegein, the Netherlands
| | - Ester M M van Leeuwen
- Department of Experimental Immunology, Academic Medical Center, University of Amsterdam, 1100AZ Amsterdam, the Netherlands
| | - Sacha Zeerleder
- Department of Hematology, Academic Medical Center, University of Amsterdam, 1100AZ Amsterdam, the Netherlands
| | - Ellen Meijer
- Department of Hematology, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Mette D Hazenberg
- Department of Hematology, Academic Medical Center, University of Amsterdam, 1100AZ Amsterdam, the Netherlands
| | - Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, 1105AZ Amsterdam, the Netherlands
| | - Abraham Goorhuis
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, 1105AZ Amsterdam, the Netherlands.
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12
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Revaccination after Autologous Hematopoietic Stem Cell Transplantation Is Safe and Effective in Patients with Multiple Myeloma Receiving Lenalidomide Maintenance. Biol Blood Marrow Transplant 2017; 24:871-876. [PMID: 29288818 DOI: 10.1016/j.bbmt.2017.12.795] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 12/18/2017] [Indexed: 02/07/2023]
Abstract
Guidelines recommend vaccination starting 12 months after autologous hematopoietic stem cell transplant (aHCT), but there is varying practice for patients on maintenance therapy, with some centers not immunizing at all. Because of decreased vaccine rates among the general population causing loss of herd immunity, we aimed to establish the safety and efficacy of revaccinating multiple myeloma patients on lenalidomide maintenance (LM). Of the 122 patients who were vaccinated after aHCT between 2010 and 2014 at Memorial Sloan Kettering Cancer Center, 91 (75%) were on LM. Vaccine responses were defined by increases between pre- and postvaccination titers. Reponses varied by vaccine type with 76% responding to pertussis, 70% diphtheria, 60% tetanus, 71% Haemophilus influenzae, and 58% pneumococcal. All patients retained minimal levels of polio immunity, but 27% responded with increased titers. Fewer patients received hepatitis A and B, but of those who did, 30% responded to hepatitis A and 40% to hepatitis B. No differences were seen in rates of response for those on LM at time of vaccination compared with those who were not. There were no vaccine-related adverse effects. Reimmunization with inactivated vaccines in patients on LM is therefore both safe and effective, offering this population immunity to vaccine-preventable diseases.
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13
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Influenza and Pneumococcal Vaccination in Hematological Malignancies: a Systematic Review of Efficacy, Effectiveness, and Safety. Mediterr J Hematol Infect Dis 2016; 8:e2016044. [PMID: 27648207 PMCID: PMC5016013 DOI: 10.4084/mjhid.2016.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 12/13/2022] Open
Abstract
Background The risk of getting influenza and pneumococcal disease is higher in cancer patients, and serum antibody levels tend to be lower in patients with hematological malignancy. Objective To assess flu and pneumococcal vaccinations efficacy, effectiveness, and safety in onco-hematological patients. Methods Two systematic reviews and possible meta-analysis were conducted to summarize the results of all primary study in the scientific literature about the flu and pneumococcal vaccine in onco-hematological patients. Literature searches were performed using Pub-Med and Scopus databases. StatsDirect 2.8.0 was used for the analysis. Results 22 and 26 studies were collected respectively for flu and pneumococcal vaccinations. Protection rate of booster dose was 30% (95% CI=6–62%) for H1N1. Pooled prevalence protection rate of H3N2 and B was available for meta-analysis only for first dose, 42.6% (95% CI=23.2 – 63.3 %) and 39.6 % (95% CI=26%–54.1%) for H3N2 and B, respectively. Response rate of booster dose resulted 35% (95% CI=19.7–51.2%) for H1N1, 23% (95% CI=16.6–31.5%) for H3N2, 29% (95% CI=21.3–37%) for B. Conclusion Despite the low rate of response, flu, and pneumococcal vaccines are worthwhile for patients with hematological malignancies. Patients undergoing chemotherapy in particular rituximab, splenectomy, transplant recipient had lower and impaired response. No serious adverse events were reported for both vaccines.
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14
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Bacterial meningitis in hematopoietic stem cell transplant recipients: a population-based prospective study. Bone Marrow Transplant 2016; 51:1490-1495. [DOI: 10.1038/bmt.2016.181] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/24/2016] [Accepted: 05/27/2016] [Indexed: 11/08/2022]
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15
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How I vaccinate blood and marrow transplant recipients. Blood 2016; 127:2824-32. [PMID: 27048212 DOI: 10.1182/blood-2015-12-550475] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 03/30/2016] [Indexed: 11/20/2022] Open
Abstract
Vaccination guidelines for recipients of blood and marrow transplantation (BMT) have been published by 3 major societies: American Blood and Marrow Transplantation, European Group of Blood and Marrow Transplantation, and Infectious Disease Society of America. Despite these extensive review articles, clinicians caring for BMT recipients continue to field frequently asked questions (FAQs) regarding the "who, when, and how" of feasible and effective posttransplant vaccination, frequently in the absence of adequate data. This may reflect discomfort with a "one size fits all" policy that makes no adjustments for different posttransplant clinical scenarios. Existing guidelines also lack practical dose clarifications when administering vaccines to patients who differ by age, underlying diagnosis, or amount of immunosuppressive therapy. Frequently, little or conflicting guidance is given regarding age-related schedules for certain vaccines (eg, meningococcal; tetanus toxoid, reduced diphtheria toxoid, and reduced acellular pertussis; and human papillomavirus vaccines) in addition to time posttransplant or other factors. FAQs and their answers form the body of this article and are shared with readers as a concise practical review, with the intent to facilitate good clinical practice.
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Boosting humoral and cellular immunity to pneumococcus by vaccination before and just after autologous transplant for myeloma. Bone Marrow Transplant 2015; 51:291-4. [PMID: 26457911 DOI: 10.1038/bmt.2015.239] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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17
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Fletcher MA, Balmer P, Bonnet E, Dartois N. PCVs in individuals at increased risk of pneumococcal disease: a literature review. Expert Rev Vaccines 2015; 14:975-1030. [DOI: 10.1586/14760584.2015.1037743] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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Harris AE, Styczynski J, Bodge M, Mohty M, Savani BN, Ljungman P. Pretransplant vaccinations in allogeneic stem cell transplantation donors and recipients: an often-missed opportunity for immunoprotection? Bone Marrow Transplant 2015; 50:899-903. [PMID: 25798674 DOI: 10.1038/bmt.2015.49] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 01/27/2015] [Accepted: 01/31/2015] [Indexed: 11/09/2022]
Abstract
Immune deficiency following hematopoietic cell transplantation predisposes the patient to potentially deadly infections. Vaccinations can improve immunity and thus reduce the morbidity and mortality associated with these infections. Over the years different sets of guidelines have been published the most recent by the Infectious Diseases Society of American (IDSA). There is limited evidence that vaccination of donors and/or recipients before transplantation may improve immunity. However, despite the possibility of augmented immunity, there remain logistical, ethical and medical concerns about such a vaccination strategy.
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Affiliation(s)
- A E Harris
- Section of Hematology and Stem Cell Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - M Bodge
- Department of Pharmacy, Veterans Affairs Medical Center, Nashville, TN, USA
| | - M Mohty
- 1] Department of Haematology, Saint Antoine Hospital, Paris, France [2] INSERM UMR 938, Paris, France [3] Université Pierre et Marie Curie, Paris, France
| | - B N Savani
- Section of Hematology and Stem Cell Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - P Ljungman
- 1] Departments of Hematology and Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden [2] Division of Hematology, Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden
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19
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McIntosh EDG. Treatment and prevention strategies to combat pediatric pneumococcal meningitis. Expert Rev Anti Infect Ther 2014; 3:739-50. [PMID: 16207165 DOI: 10.1586/14787210.3.5.739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pneumococcal meningitis is a severe, life-threatening infection of the nervous system affecting infants, children and adults alike. The incidence of pneumococcal meningitis in infants and children less than 2 years of age in Europe is approximately 10 out of 100,000 per year, rising to approximately 148 out of 100,000 per year in Gambian infants. The use of highly sensitive tests such as PCR may increase the likelihood of detecting the infection by 20% or more. Epidemics of serotype 1 pneumococcal meningitis in northern Ghana, have had many of the characteristics of meningococcal meningitis epidemics. Neurologic sequelae may occur in 28-63% of cases, and serotype 3 is associated with a 2.54 relative risk of death. The pathogenic process can be divided into invasion, inflammatory pathways, bacterial toxicity and damage; pneumolysin being particularly associated with apoptosis. In the future, neuroprotection may be achieved, targeting this process at all these levels. Therapeutic guidelines have been published by the Infectious Diseases Society of America. Standard empiric therapy, in those aged greater than or equal to 1 month, is a third-generation cephalosporin plus vancomycin. There is insufficient evidence relating to the use or otherwise of corticosteroids in pneumococcal meningitis to make a firm recommendation. The advent of a pneumococcal conjugate vaccine is the most powerful tool available for the prevention of pneumococcal meningitis in all parts of the world.
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20
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Cordonnier C, Averbuch D, Maury S, Engelhard D. Pneumococcal immunization in immunocompromised hosts: where do we stand? Expert Rev Vaccines 2013; 13:59-74. [PMID: 24308578 DOI: 10.1586/14760584.2014.859990] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Immunocompromised patients are all at risk of invasive pneumococcal disease, of different degrees and timings. However, considerable progress in pneumococcal immunization over the last 30 years should benefit these patients. The 23-valent polysaccharide vaccine has been widely evaluated in these populations, but due to its low immunogenicity, its efficacy is sub-optimal, or even low. The principle of the conjugate vaccine is that, through the protein conjugation with the polysaccharide, the vaccine becomes more immunogenic, T-cell dependent, and thus providing a better early response and a boost effect. The 7-valent conjugate vaccine has been the first one to be evaluated in different immunocompromised populations. We review here the efficacy and safety of the different antipneumococcal vaccines in cancer, transplant and HIV-positive patients and propose a critical appraisal of the current guidelines.
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Affiliation(s)
- Catherine Cordonnier
- Hematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and Université Paris-Est-Créteil, Créteil 94000, France
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21
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Mitchell R, Trück J, Pollard AJ. Use of the 13-valent pneumococcal conjugate vaccine in children and adolescents aged 6 - 17 years. Expert Opin Biol Ther 2013; 13:1451-65. [PMID: 23889554 DOI: 10.1517/14712598.2013.824419] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION The introduction of pneumococcal conjugate vaccines into infant immunization schedules has successfully reduced the incidence of pneumococcal disease caused by vaccine serotypes. Disease incidence is low in healthy 6 - 17-year-old children and young people; however, there are a number of clinical conditions that put individuals in this age group at increased risk. Expansion of the license of a 13-valent pneumococcal conjugate vaccine , PCV-13, to include the 6 - 17 age group has recently been approved by European and American regulatory bodies. AREAS COVERED Studies assessing the safety, immunogenicity, and efficacy of pneumococcal conjugate vaccines in both healthy and high-risk 6 - 17-year-old children and adolescents are covered and the potential impact of PCV-13 in these populations is discussed. The use of the 23-valent pneumococcal polysaccharide vaccine, PPV-23, in high-risk children and adolescents is also considered. EXPERT OPINION Expanding the use of PCV-13 to include high-risk children and adolescents aged 6 - 17 has the potential to prevent additional cases of disease; however, vaccination of this population may no longer be necessary when herd immunity to PCV-13 serotypes becomes fully established. Despite the broader serotype coverage of PPV-23, the benefits of this vaccine in high-risk populations are uncertain.
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Affiliation(s)
- Ruth Mitchell
- University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine (CCVTM), Churchill Hospital, Department of Paediatrics, Oxford Vaccine Group , Old Road, Headington, Oxford, OX3 7LE , UK +44 0 1865 857420 ; +44 0 1865 857420 ;
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22
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Jain N, Liu H, Artz AS, Anastasi J, Odenike O, Godley LA, Joseph L, Marino S, Kline J, Nguyen V, Schouten V, Kunnavakkam R, Larson RA, Stock W, Ulaszek J, Savage PA, Wickrema A, van Besien K. Immune reconstitution after combined haploidentical and umbilical cord blood transplant. Leuk Lymphoma 2013; 54:1242-9. [PMID: 23088744 DOI: 10.3109/10428194.2012.739688] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Umbilical cord blood (UCB) stem cells are frequently employed for allogeneic stem cell transplant, but delayed myeloid and lymphoid immune reconstitution leads to increased risk of infections. We recently reported the clinical results of 45 patients enrolled on a pilot study combining UCB with a human leukocyte antigen (HLA)-haploidentical donor with reduced-intensity conditioning who showed rapid neutrophil and platelet recovery. We report here preliminary immune reconstitution data of these patients. Patients were assessed for lymphocyte subsets, T-cell diversity, Cylex ImmuKnow assay and serological response to pneumococcal vaccination. Natural killer (NK)-cell and B-cell reconstitution were rapid at 1 month and 3 months, respectively. T-cell recovery was delayed, with a gradual increase in the number of T-cells starting around 6 months post-transplant, and was characterized by a diverse polyclonal T-cell repertoire. Overall, immune reconstitution after haplo-cord transplant is similar to that seen after cord blood transplant, despite infusion of much lower cord blood cell dose.
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Affiliation(s)
- Nitin Jain
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago Medical Center, Chicago, IL, USA
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23
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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.
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Affiliation(s)
- Per Ljungman
- Department of Haematology, Karolinska University Hospital, Division of Haematology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.
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24
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Vaccination of immunocompromised hosts. Vaccines (Basel) 2013. [DOI: 10.1016/b978-1-4557-0090-5.00016-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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25
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Karlsson J, Hogevik H, Andersson K, Roshani L, Andréasson B, Wennerås C. Pneumococcal vaccine responses in elderly patients with multiple myeloma, Waldenstrom’s macroglobulinemia, and monoclonal gammopathy of undetermined significance. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.trivac.2013.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Clinical and microbiological epidemiology of Streptococcus pneumoniae bacteremia in cancer patients. J Infect 2012; 65:521-7. [PMID: 22954752 DOI: 10.1016/j.jinf.2012.08.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 08/12/2012] [Accepted: 08/29/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES In the current era of changing epidemiology of invasive pneumococcal disease, we aimed to assess the clinical features, antimicrobial susceptibility, vaccination status, serotypes, genotypes and outcomes of pneumococcal bacteremia in cancer patients. METHODS Prospective observational analysis of all consecutive cancer adults admitted to a university hospital (January 2006-April 2011). RESULTS Of 971 episodes of bacteremia, 63 (6.5%) were caused by Streptococcus pneumoniae. Pneumonia was the most common source of pneumococcal bacteremia (84.1%). Although all isolated pneumococci were penicillin-susceptible, resistance to ceftazidime was high (43%). The serotypes most frequently isolated were 19A and 14, and the most common genotypes were Spain(9V)-ST156 and Denmark(14)-ST230. Only 23% of patients had received the 23-valent polysaccharide pneumococcal vaccine. This polysaccharide vaccine was found to cover 72.4% of the serotypes identified, whereas the 7-valent, 10-valent and the 13-valent conjugate vaccines covered 24.1%, 29.3%, and 53.5% of serotypes respectively. The early case-fatality rate (<48 h) was 4.8% and overall case-fatality rate (<30 days) 14.3%. CONCLUSIONS Pneumococcal bacteremia, which complicates mainly pneumonia, is frequent in cancer patients and causes significant morbidity and case-fatality rate. Resistance to ceftazidime is particularly high. These findings should be considered when selecting antibiotic treatment for cancer patients presenting pneumonia.
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27
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Bunin N, Small T, Szabolcs P, Baker KS, Pulsipher MA, Torgerson T. NCI, NHLBI/PBMTC first international conference on late effects after pediatric hematopoietic cell transplantation: persistent immune deficiency in pediatric transplant survivors. Biol Blood Marrow Transplant 2012; 18:6-15. [PMID: 22100979 PMCID: PMC3253930 DOI: 10.1016/j.bbmt.2011.11.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/10/2011] [Indexed: 10/15/2022]
Abstract
Defective immune reconstitution is a major barrier to successful hematopoietic cell transplantation (HCT), and has important implications in the pediatric population. There are many factors that affect immune recovery, including stem cell source and graft-versus-host disease (GVHD). Complete assessment of immune recovery, including T and B lymphocyte evaluation, innate immunity, and response to neoantigens, may provide insight as to infection risk and optimal time for immunizations. The increasing use of cord blood grafts requires additional study regarding early reconstitution and impact upon survival. Immunization schedules may require modification based upon stem cell source and immune reconstitution, and this is of particular importance as many children have been incompletely immunized, or not at all, before school entry. Additional studies are needed in children post-HCT to evaluate the impact of differing stem cell sources upon immune reconstitution, infectious risks, and immunization responses.
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Affiliation(s)
- Nancy Bunin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, 19104, USA.
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28
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Small TN, Cowan MJ. Immunization of hematopoietic stem cell transplant recipients against vaccine-preventable diseases. Expert Rev Clin Immunol 2011; 7:193-203. [PMID: 21426257 DOI: 10.1586/eci.10.103] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Worldwide, over 40,000 hematopoietic cell transplants (HCT) are carried out each year, with the majority of patients surviving long term. Owing to their new immune systems, these patients are susceptible to a variety of preventable infectious diseases. The 2009 influenza pandemic, the increase in pertussis and antibiotic-resistant pneumococcus, as well as recent outbreaks of measles and mumps in immunocompetent individuals further highlight the need for effective revaccination of HCT recipients. Post-transplant vaccine guidelines, including those published in 2009, recommend immunization of all patient groups at fixed times post-HCT. Although early vaccination to protect against vaccine-preventable diseases is desirable, there are still limited data on whether this approach is efficacious in patient groups whose immune recovery differs from recipients of an unmodified HLA-matched sibling transplant. In the absence of such data, prospective trials are needed to better define the optimal timing for immunizing recipients of alternative donors. Ideally, such trials should be designed to identify biological markers that will predict an optimal and durable vaccine response.
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Affiliation(s)
- Trudy N Small
- Department of Pediatrics, Bone Marrow Transplantation Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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29
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Brody J, Kohrt H, Marabelle A, Levy R. Active and passive immunotherapy for lymphoma: proving principles and improving results. J Clin Oncol 2011; 29:1864-75. [PMID: 21482977 DOI: 10.1200/jco.2010.33.4623] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Conventional chemotherapy for lymphoma has advanced greatly over the past 50 years, changing some lymphoma subtypes from uniformly lethal to curable; however, the majority of lymphomas in patients remain incurable, and there is a need for novel therapies with less toxicity and more specific targeting of tumor cells. The vertebrate immune system has evolved the capacity for such specific targeting through the B-cell and T-cell receptors; passive immunotherapies utilizing these receptors, such as monoclonal antibodies (mAbs) or T cells, have shown efficacy in treating lymphomas. The first generation of mAb-based therapies has transformed the standard of care for lymphoma, and newer antibodies may improve on this approach. Clinical activity has been shown by T cells bearing receptors that target viral antigens as well as T cells bearing re-engineered receptors that target antigens recognized by antibodies. Active immunotherapies, such as vaccines and immune checkpoint blockades, have prolonged survival in certain solid tumors and are being actively pursued to treat lymphoma. A variety of vaccines (eg, protein- and cell-based vaccines) are being tested in ongoing trials, and the most recent iterations show therapeutic activity. Newer trials are addressing the problem of tumor-induced immunosuppression by the use of antibodies against immunologic checkpoints or by the reinfusion of primed T cells after lymphodepletion, a process we refer to as immunotransplantation. Herein, we discuss results of the various immunotherapy strategies applied to lymphoma and the ongoing approaches for their improvement.
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Affiliation(s)
- Joshua Brody
- Division of Oncology, Department of Medicine, Stanford University Medical Center, Stanford, CA 94305, USA.
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30
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Brody J, Levy R. Lymphoma immunotherapy: vaccines, adoptive cell transfer and immunotransplant. Immunotherapy 2009; 1:809-24. [PMID: 20636025 PMCID: PMC5469410 DOI: 10.2217/imt.09.50] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Therapy for non-Hodgkin lymphoma has benefited greatly from basic science and clinical research such that chemotherapy and monoclonal antibody therapy have changed some lymphoma subtypes from uniformly lethal to curable, but the majority of lymphoma patients remain incurable. Novel therapies with less toxicity and more specific targeting of tumor cells are needed and immunotherapy is among the most promising of these. Recently completed randomized trials of idiotype vaccines and earlier-phase trials of other vaccine types have shown the ability to induce antitumor T cells and some clinical responses. More recently, trials of adoptive transfer of antitumor T cells have demonstrated techniques to increase the persistence and antitumor effect of these cells. Herein, we discuss lymphoma immunotherapy clinical trial results and what lessons can be taken to improve their effect, including the combination of vaccination and adoptive transfer in an approach we have dubbed 'immunotransplant'.
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Affiliation(s)
- Joshua Brody
- Division of Oncology, Department of Medicine, Stanford University Medical Center, CA 94305, USA.
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31
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Debbache K, Varon E, Hicheri Y, Legrand P, Donay JL, Ribaud P, Cordonnier C. The epidemiology of invasive Streptococcus pneumoniae infections in onco-haematology and haematopoietic stem cell transplant patients in France. Are the serotypes covered by the available anti-pneumococcal vaccines? Clin Microbiol Infect 2009; 15:865-8. [DOI: 10.1111/j.1469-0691.2009.02810.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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32
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Worth LJ, Slavin MA. Bloodstream infections in haematology: risks and new challenges for prevention. Blood Rev 2008; 23:113-22. [PMID: 19046796 DOI: 10.1016/j.blre.2008.10.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Bloodstream infections are an important cause of morbidity and mortality in the haematology population, and may contribute to delayed administration of chemotherapy, increased length of hospitalisation, and increased healthcare expenditure. For gram-positive, gram-negative, anaerobic and fungal infections, specific risk factors are recognised. Unique host and environmental factors contributing to pathogenesis are acknowledged in this population. Trends in spectrum and antimicrobial susceptibility of pathogens are examined, and potential contributing factors are discussed. These include the widespread use of empiric antimicrobial therapy, increasingly intensive chemotherapeutic regimens, frequent use of central venous catheters, and local infection control practices. In addition, the risks and benefits of prophylaxis, and spectrum of endemic flora are identified as relevant factors within individual centres. Finally, challenges are presented regarding prevention, early detection, surveillance and prophylaxis. To reduce the rate and impact of bloodstream infections multifaceted and customised strategies are required within individual haematology units.
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Affiliation(s)
- Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria, Australia.
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33
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Vaccination after stem cell transplant: a review of recent developments and implications for current practice. Curr Opin Infect Dis 2008; 21:399-408. [DOI: 10.1097/qco.0b013e328307c7c5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Kumar D, Chen MH, Welsh B, Siegal D, Cobos I, Messner HA, Lipton J, Humar A. A Randomized, Double-Blind Trial of Pneumococcal Vaccination in Adult Allogeneic Stem Cell Transplant Donors and Recipients. Clin Infect Dis 2007; 45:1576-82. [DOI: 10.1086/523583] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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35
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Ferrara JLM, Anasetti C, Stadtmauer E, Antin J, Wingard J, Lee S, Levine J, Schultz K, Appelbaum F, Negrin R, Giralt S, Bredeson C, Heslop H, Horowitz M. Blood and Marrow Transplant Clinical Trials Network State of the Science Symposium 2007. Biol Blood Marrow Transplant 2007; 13:1268-85. [PMID: 17950914 DOI: 10.1016/j.bbmt.2007.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Accepted: 08/20/2007] [Indexed: 11/16/2022]
Abstract
Outcomes of hematopoietic cell transplantation are steadily improving. New techniques have reduced transplant toxicities, and there are new sources of hematopoietic stem cells from unrelated donors. In June 2007 the Blood and Marrow Transplant Clinical Trials Network convened a State of the Science Symposium of more than 200 participants in Ann Arbor to identify the most compelling clinical research opportunities in the field. This report summarizes the symposium's discussions and identifies eleven high priority clinical trials that the network plans to pursue over the course of the next several years.
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36
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Cross AS, Chen WH, Levine MM. A case for immunization against nosocomial infections. J Leukoc Biol 2007; 83:483-8. [PMID: 18070981 DOI: 10.1189/jlb.0607379] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Immunization is a highly effective public health measure that reduces the incidence of infectious diseases, yet there has been relatively little effort toward the development of vaccines for nosocomial infections. Many nosocomial infections originate on mucosal surfaces (e.g., respiratory or gastrointestinal mucosa). As patients who are hospitalized once are more likely to be hospitalized again, we propose a prime-boost immunization strategy, whereby a priming dose of vaccine for a nosocomial infection is administered mucosally. Upon readmission, a parenteral boost would elicit a rapid immune response locally and systemically. Such a strategy could reduce or ameliorate nosocomial infections and perhaps limit dissemination of nosocomial pathogens. Thus, a more aggressive effort to develop vaccines for nosocomial infections is warranted.
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Affiliation(s)
- Alan S Cross
- Department of Medicine, University of Maryland School of Medicine, 685 W. Baltimore Street, Baltimore, MD 21201, USA.
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37
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van der Velden AMT, Claessen AME, van Velzen-Blad H, de Groot MR, Kramer MHH, Biesma DH, Rijkers GT. Vaccination responses and lymphocyte subsets after autologous stem cell transplantation. Vaccine 2007; 25:8512-7. [PMID: 17996989 DOI: 10.1016/j.vaccine.2007.10.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2006] [Revised: 08/26/2007] [Accepted: 10/07/2007] [Indexed: 11/19/2022]
Abstract
Twenty autologous stem cell transplant recipients were vaccinated with three doses of Diphtheria-Tetanus-Poliomyelitis vaccine and conjugated Haemophilus influenzae type b (Hib) vaccine. Pneumococcal vaccination consisted of two doses of conjugated vaccine followed by a single dose of polysaccharide vaccine, at 6, 8 and 14 months after transplantation, respectively. Mean anti-tetanus, anti-Hib and anti-pneumococcal IgG antibodies significantly increased after each vaccination. Response rates after the full vaccination schedule were 94%, 78% and 61% for Hib, conjugated 7-valent pneumococcal vaccine and non-conjugated 23-valent pneumococcal vaccine, respectively. Three months after transplantation, CD16(+)CD56(+) NK cells were in the normal range and remained so. The total number of T lymphocytes at 3 months was and remained in the normal range. The mean CD4/CD8 ratio was 0.43 at 3 months post aSCT and, while gradually increasing, remained subnormal. The mean number of CD19(+) B lymphocytes significantly increased during the study period. Patients with CD19 counts <0.10 x 10(9)L(-1) required at least two Hib vaccinations to show a response, while the majority of patients with CD19 counts > or = 0.20 x 10(9)L(-1) showed a response to Hib after one vaccination only. Thus, a minimum threshold level of CD19(+) cells appears to be required for adequate responses to vaccination.
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Affiliation(s)
- A M T van der Velden
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, The Netherlands.
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38
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Styczyński J, Gil L. Strategies for prevention of infectious complications in children after HSCT in relation to type of transplantation and GVHD occurrence. Rep Pract Oncol Radiother 2007. [DOI: 10.1016/s1507-1367(10)60050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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39
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Balmer P, Cant AJ, Borrow R. Anti-pneumococcal antibody titre measurement: what useful information does it yield? J Clin Pathol 2007; 60:345-50. [PMID: 16950855 PMCID: PMC2001126 DOI: 10.1136/jcp.2006.041210] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2006] [Indexed: 11/04/2022]
Abstract
Measuring and interpretation of the immune response to pneumococcal polysaccharides is a complex field, owing to the diversity of the pneumococcal polysaccharide capsular types, different vaccine formulations including both polysaccharide and conjugate vaccines, diverse pneumococcal serological assays, lack of immunogenicity data for the conjugate in a number of at-risk groups and complex vaccine schedules. Even the reasons for performing pneumococcal serology can be complex, as assays may be performed for one of two reasons: either to assess an individual's immune status to the pneumococcus or to discriminate between normal and abnormal humoral immunity. This review details a history of the pneumococcal serological assays and provides some insight into when serology can prove useful, including vaccination data for certain at-risk groups.
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Affiliation(s)
- Paul Balmer
- Vaccine Evaluation Unit, Health Protection Agency North West, Manchester Laboratory, Manchester Royal Infirmary, Manchester, UK
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40
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41
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Rapoport AP. Immunity for tumors and microbes after autotransplantation: if you build it, they will (not) come. Bone Marrow Transplant 2005; 37:239-47. [PMID: 16327812 DOI: 10.1038/sj.bmt.1705242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Relapses after autologous stem cell transplants for hematopoietic malignancies are frequent and post-transplant infections continue to cause significant post-transplant morbidity and even mortality. The post-transplant period is typically characterized by low lymphocyte counts and impaired immune cell function. Early restoration of immune function may contribute to better disease control and enhance protection from infections. Indeed the attainment of a 'minimal residual disease' status following high-dose therapy makes the early post-transplant period ideal for the introduction of antitumor immunotherapy. Attempts to generate immunity against tumor and microbial antigens after autotransplantation have included vaccinations, T cell infusions (both resting and activated) and combinations of vaccinations and adoptive T cell infusions. One successful strategy for generating robust immune responses against microbial antigens was the combination of pre and post-transplant immunizations along with an early (post-transplant) infusion of in vivo vaccine-primed and ex vivo co-stimulated autologous T cells. Whether this or similar strategies will lead to the generation of effective antitumor immunity is unknown. The lessons gained from efforts to rebuild immune system function in the setting of autotransplantation may also be applicable to the problem of restoring immunity in other immunodeficient groups such as patients with cancer or HIV disease and the elderly.
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Affiliation(s)
- A P Rapoport
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD 21201, USA.
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Rapoport AP, Stadtmauer EA, Aqui N, Badros A, Cotte J, Chrisley L, Veloso E, Zheng Z, Westphal S, Mair R, Chi N, Ratterree B, Pochran MF, Natt S, Hinkle J, Sickles C, Sohal A, Ruehle K, Lynch C, Zhang L, Porter DL, Luger S, Guo C, Fang HB, Blackwelder W, Hankey K, Mann D, Edelman R, Frasch C, Levine BL, Cross A, June CH. Restoration of immunity in lymphopenic individuals with cancer by vaccination and adoptive T-cell transfer. Nat Med 2005; 11:1230-7. [PMID: 16227990 DOI: 10.1038/nm1310] [Citation(s) in RCA: 256] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Accepted: 09/13/2005] [Indexed: 11/08/2022]
Abstract
Immunodeficiency is a barrier to successful vaccination in individuals with cancer and chronic infection. We performed a randomized phase 1/2 study in lymphopenic individuals after high-dose chemotherapy and autologous hematopoietic stem cell transplantation for myeloma. Combination immunotherapy consisting of a single early post-transplant infusion of in vivo vaccine-primed and ex vivo costimulated autologous T cells followed by post-transplant booster immunizations improved the severe immunodeficiency associated with high-dose chemotherapy and led to the induction of clinically relevant immunity in adults within a month after transplantation. Immune assays showed accelerated restoration of CD4 T-cell numbers and function. Early T-cell infusions also resulted in significantly improved T-cell proliferation in response to antigens that were not contained in the vaccine, as assessed by responses to staphylococcal enterotoxin B and cytomegalovirus antigens (P < 0.05). In the setting of lymphopenia, combined vaccine therapy and adoptive T-cell transfer fosters the development of enhanced memory T-cell responses.
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Affiliation(s)
- Aaron P Rapoport
- University of Maryland Greenebaum Cancer Center and Center for Vaccine Development, 22 South Greene Street Baltimore, Maryland 21201, USA.
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