Influenza vaccination in adult patients with solid tumours treated with chemotherapy

Immune response of COVID-19 vaccines in solid cancer patients: A meta-analysis

Solid cancer patients, compared to their healthy counterparts, are at a greater risk of contracting and suffering from severe complications and poorer prognosis after COVID-19 infections. They also have different immune responses after doses of COVID-19 vaccination, but limited evidence is available to reveal the effectiveness and help to guide immunization programs for this subpopulation; MEDLINE, Embase, Web of Science, Cochrane Library databases, and clinicaltrials.gov were used to search literature. The pooled seroconversion rate was calculated using a random-effects model and reported with a 95% confidence interval (CI); The review includes 66 studies containing serological responses after COVID-19 vaccination in 13,050 solid cancer patients and 8550 healthy controls. The pooled seropositive rates after the first dose in patients with solid cancer and healthy controls are 55.2% (95% CI 45.9%-64.5% N = 18) and 90.2% (95% CI 80.9%-96.6% N = 13), respectively. The seropositive rates after the second dose in patients with solid cancer and healthy controls are 87.6% (95% CI 84.1%-90.7% N = 50) and 98.9% (95% CI 97.6%-99.7% N = 35), respectively. The seropositive rates after the third dose in patients with solid cancer and healthy controls are 91.4% (95% CI 85.4%-95.9% N = 21) and 99.8% (95% CI 98.1%-100.0% N = 4), respectively. Subgroup analysis finds that study sample size, timing of antibody testing, and vaccine type have influence on the results; Seroconversion rates after COVID-19 vaccination are significantly lower in patients with solid malignancies, especially after the first dose, then shrinking gradually after the following two vaccinations, indicating that subsequent doses or a booster dose should be considered for the effectiveness of this subpopulation.

Changes in vaccination uptake against pneumococcal disease, influenza, and coronavirus disease 2019 (COVID-19) before and after a Head and Neck cancer diagnosis

BACKGROUND

Pneumonia is one of the main contributors to non-cancer mortality among patients with head and neck cancer (HNC). This study aimed to determine the vaccine uptake for pneumococcal polysaccharide and conjugate vaccines, quadrivalent influenza vaccines, and mRNA COVID-19 vaccines before and after an HNC diagnosis. Furthermore, the study investigated the timing of vaccination after a cancer diagnosis.

MATERIALS & METHODS

This register based multicentre study included Danish patients ≥ 18y diagnosed with HNC between 2018 and 2021. The vaccine uptake was assessed by calculating cumulative incidence (CI), while the timing of vaccination after an HNC diagnosis was explored by calculating incidence rates of vaccination the first and second half year after a cancer diagnosis.

RESULTS

The cumulative incidence of vaccine uptake for pneumococcal vaccines was estimated to be 8 % and 16 % one year before and after an HNC diagnosis, respectively. The CIs were 36 % and 38 % for quadrivalent influenza vaccines, respectively, whereas the CIs of vaccine uptake for mRNA COVID-19 vaccines were 60 % and 89 %. The IR of mRNA COVID-19 vaccinations the first half year after HNC diagnosis were 273 per 1000 person-months of follow-up (PMFU) and 111 per 1000 PMFU the second half year, respectively (IRR: 0.38, p < 0.001). Comparing the same periods, the IR of quadrivalent influenza vaccination was 28 per 1000 PMFU and 51 per 1000 PMFU (IRR: 1.95, 0 < 0.001). The IRs of pneumococcal vaccinations were 11 per 1000 PMFU and 14 per 1000 PMFU (IRR 1.28, p = 0.21).

CONCLUSIONS

Although our study shows a significant increase in pneumococcal and COVID-19 vaccine uptake after HNC diagnosis, a gap remains in vaccine uptake before diagnosis, underscoring the need for increased awareness of vaccination options and recommendations. Our findings could serve as a reference for future recommendations.

Vaccination of Adults With Cancer: ASCO Guideline

PURPOSE

To guide the vaccination of adults with solid tumors or hematologic malignancies.

METHODS

A systematic literature review identified systematic reviews, randomized controlled trials (RCTs), and nonrandomized studies on the efficacy and safety of vaccines used by adults with cancer or their household contacts. This review builds on a 2013 guideline by the Infectious Disease Society of America. PubMed and the Cochrane Library were searched from January 1, 2013, to February 16, 2023. ASCO convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

A total of 102 publications were included in the systematic review: 24 systematic reviews, 14 RCTs, and 64 nonrandomized studies. The largest body of evidence addressed COVID-19 vaccines.

RECOMMENDATIONS

The goal of vaccination is to limit the severity of infection and prevent infection where feasible. Optimizing vaccination status should be considered a key element in the care of patients with cancer. This approach includes the documentation of vaccination status at the time of the first patient visit; timely provision of recommended vaccines; and appropriate revaccination after hematopoietic stem-cell transplantation, chimeric antigen receptor T-cell therapy, or B-cell-depleting therapy. Active interaction and coordination among healthcare providers, including primary care practitioners, pharmacists, and nursing team members, are needed. Vaccination of household contacts will enhance protection for patients with cancer. Some vaccination and revaccination plans for patients with cancer may be affected by the underlying immune status and the anticancer therapy received. As a result, vaccine strategies may differ from the vaccine recommendations for the general healthy adult population vaccine.Additional information is available at www.asco.org/supportive-care-guidelines.

Vaccinomics and adversomics: key elements for a personalized vaccinology

Vaccines are one of the most important and effective tools in the prevention of infectious diseases and research about all the aspects of vaccinology are essential to increase the number of available vaccines more and more safe and effective. Despite the unquestionable value of vaccinations, vaccine hesitancy has spread worldwide compromising the success of vaccinations. Currently, the main purpose of vaccination campaigns is the immunization of whole populations with the same vaccine formulations and schedules for all individuals. A personalized vaccinology approach could improve modern vaccinology counteracting vaccine hesitancy and giving great benefits for human health. This ambitious purpose would be possible by facing and deepening the areas of vaccinomics and adversomics, two innovative areas of study investigating the role of a series of variables able to influence the immune response to vaccinations and the development of serious side effects, respectively. We reviewed the recent scientific knowledge about these innovative sciences focusing on genetic and non-genetic basis involved in the individual response to vaccines in terms of both immune response and side effects.

Impact of Actively Offering Influenza Vaccination to Frail People during Hospitalisation: A Pilot Study in Italy

Despite the worldwide recommendations for influenza immunisation, vaccination coverage for patients exposed to the highest risk of severe complications is still far from the optimal target. The need to take advantage of alternative methods to provide vaccination is essential. This study presents a hospital-based strategy which offers influenza vaccination to inpatients at discharge. This study was conducted during the 2022-2023 influenza season at the University Hospital of Palermo. A questionnaire was administered to identify the determinants for the acceptance of influenza vaccination in the frail population. Overall, 248 hospitalised patients were enrolled, of which 56.1% were female and 52.0% were over 65 years of age. The proportion of patients vaccinated against influenza during hospitalisation was 62.5%, an increase of 16% in influenza vaccination uptake among frail people in comparison with the previous influenza season (46.8% vaccinated during the 2021-22 influenza season). Factors significantly associated with vaccination acceptance were the following: to have received influenza vaccine advice from hospital healthcare workers (OR = 3.57, p = 0.001), to have been previously vaccinated for influenza (OR = 3.16 p = 0.005), and to have had a low level of education (OR = 3.56, p = 0.014). This study showed that offering influenza vaccination to hospitalised patients could be an effective strategy to increase vaccination coverage in the most vulnerable population, and these findings could be useful for planning and improving future influenza vaccination campaigns.

Review of Vaccination Recommendations in Guidelines for Non-Communicable Diseases with Highest Global Disease Burden among Adults 75 Years Old and Above

This scientific review paper explores international and country-specific healthcare guidelines for non-communicable diseases with the highest burden among individuals aged 75 years and above. The study aims to identify the best vaccination practices and standardize healthcare practices to improve vaccination adherence in this vulnerable population. Given that older people are more prone to infectious illnesses and have higher rates of morbidity and mortality, vaccinations are essential for disease prevention. Despite the proven efficacy of vaccinations, adherence has plateaued in recent years, partly due to a lack of accessibility, public education, and variability in disease-specific guidelines. This paper highlights the need for a more robust and standardized international vaccination model to improve quality of life and reduce disability-adjusted life years among the elderly. The findings of this study call for further research to review the guidelines as more implementations are put in place, including non-English guidelines.

Vaccination for seasonal flu, pneumococcal infection, and SARS-CoV-2 in patients with solid tumors: recommendations of the Associazione Italiana di Oncologia Medica (AIOM)

Patients with cancer have a well-known and higher risk of vaccine-preventable diseases (VPDs). VPDs may cause severe complications in this setting due to the immune system impairment, malnutrition and oncological treatments. Despite this evidence, vaccination rates are inadequate. The Italian Association of Medical Oncology (AIOM) has been involved in vaccination awareness since 2014. Based on a careful review of the available data about the immunogenicity, effectiveness and safety of flu, pneumococcal and anti-SARS-CoV-2 vaccines, we report the recommendations of the Associazione Italiana di Oncologia Medica about these vaccinations in adult patients with solid tumors. AIOM recommends comprehensive education on the issue of VPDs. We believe that a multidisciplinary care model may improve the vaccination coverage in immunocompromised patients. Continued surveillance, implementation of preventive practices and future well-designed immunological prospective studies are essential for a better management of our patients with cancer.

Determinants of humoral immune response to SARS-CoV-2 vaccines in solid cancer patients: A systematic review and meta-analysis

IMPORTANCE

Solid cancer patients following SARS-CoV-2 vaccination are likely to have a lower seroconversion rate than healthy adults. Seroconversion between those with and without cancer is likely to vary moderately or to be restricted to specific subgroups. Therefore, we sought to conduct a systematic review and meta-analysis to identify risk factors for diminished humoral immune responses in solid cancer patients.

METHODS

MEDLINE, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov were used to search literature through May 1, 2022. Prospective or retrospective studies comparing responders with non-responders against SARS-CoV-2 spike (S) protein receptor-binding domain (RBD) following COVID-19 vaccination were included. Pooled Odds Ratios (pORs) with 95% CIs for binary variables and differences in means (with SDs) for continuous variables were calculated to determine the pooled effect estimates of risk factors for poor antibody response.

RESULTS

Fifteen studies enrolling 3593 patients were included in the analysis. Seroconversion was seen in 84% of the pooled study population. Male gender, age >65 years, and recent chemotherapy were all factors in a poor immune response. Patients under follow-up, those who received immunotherapy or targeted therapy, were more likely to be seropositive. Cancer subtypes, vaccine types, and timing of antibody testing from the 2nd dose of vaccine did not correlate with seroconversion.

CONCLUSION

Cytotoxic therapy for solid cancer may portend poor immune response following 2 doses of COVID-19 vaccines suggesting a need for booster doses in these patients. Immunotherapy and targeted therapy are likely to be associated with seropositive status, and thus can be considered as an alternative to cytotoxic agents in cases where both therapies are equally efficacious.

The evaluation of vaccination status and the factors affecting vaccination in cancer patients

Background and aim: Coronavirus disease 2019 (COVID-19) pandemic increased the mortality of cancer patients by causing direct infection or collateral damage to the healthcare system. After the development of effective vaccines against COVID-19 infection, mortality rates declined. In this study, we try to investigate the vaccination among cancer patients. Material and Methods: A survey was applied to patients with cancer in order to investigate the attitudes towards vaccination and the factors effecting vaccination in two medical oncology centers in Turkey. Results: 271 patients were included in the study. No difference was observed in the attitudes of patients towards vaccination according to cancer type. 83% of the patients were vaccinated against COVID-19. In 75% of the study population, vaccine was administered in the earliest available time. Receiving chemotherapy was the most significant reason to avoid vaccination among the study group (p=0,002). There was no significant difference in terms of treatment type for COVID-19 between patients with or without adequate vaccination. The most negative factor affecting vaccination was active chemotherapy treatment. Social relations and traditional media were the most positive factors for vaccination. Discussion: Vaccination is of vital importance for patients who are treated or on remission. Even if patients are to receive chemotherapy, they should be informed about vaccination and should be encouraged for vaccination.

Generation of Human Lung Organoid Cultures from Healthy and Tumor Tissue to Study Infectious Diseases

Three-dimensional (3D) human lung organoids reflect the native cell composition of the lung as well as its physiological properties. Human 3D lung organoids offer ideal conditions, such as timely availability in large quantities and high physiological relevance for reassessment and prediction of disease outbreaks of respiratory pathogens and pathogens that use the lung as a primary entry portal.

Investigation of anxiety sensitivity levels of cancer patients in terms of COVID-19 vaccine: a cross-sectional study

INTRODUCTION

Our study's purpose was to investigate the viewpoints of cancer patients who had not yet been vaccinated. Cancer patients usually cannot get every vaccine because their immunity is low. For this reason, we aimed to detect their anxiety and curiosity for new vaccines for a new disease.

METHODS

The goal of this descriptive cross-sectional study was to investigate cancer patients' perceptions of COVID vaccination. Over 18 years of age who have not yet been vaccinated for COVID-19 and who agreed to participate were included in the study. We applied three questionnaires between May and June 2021, one of them was prepared by us; the other two questionnaires were The State-Trait Anxiety Inventory (STAI) form and Anxiety Sensitivity index to a total of 497 participants. Chi-square, Spearmen correlation test, and multivariable multinomial logistic regression tests were used when comparing.

RESULTS

Our participants' ages were between 21 and 88, with a mean age of 61.38 (SD = 11.68), 48.6% (n = 251) of the participants were female. We discovered that 79.1% (n = 408) of respondents were not afraid of getting the COVID-19 vaccine. 27.7% (n = 143) of these patients were concerned about the COVID-19 vaccine's adverse effects, and 24.2% (n = 125) were afraid of its side effects with their treatments. 91.1% (n = 470) of the patients did not know which vaccine they would have and the type of the vaccine. Since the anxiety level is generally higher in women, anxiety scores were also higher in cancers seen in women, such as breast and ovarian cancer. Of course, in parallel with this, anxiety scores were lower in prostate cancers. Special patient groups should not be neglected during this vaccine season, and their concerns should be addressed. When a new vaccine is found, it can have long-term effects, which should not be ignored.

BNT162b2 mRNA COVID-19 vaccination in immunocompromised patients: A prospective cohort study

BACKGROUND

Trials of the Pfizer-BioNTech BNT162b2 mRNA vaccine showed 95% efficacy in preventing symptomatic disease; however, the trials excluded immunocompromised patients (ICPs). We aim at analyzing antibody response in ICPs.

METHODS

A prospective cohort study was conducted at Sheba Medical Center, Israel, between January and April 2020, in 1274 participants who received the vaccine, including 1002 ICPs and 272 immunocompetent healthcare workers (HCWs). Antibodies were measured two-four weeks after vaccination by SARS-CoV-2 anti-receptor binding domain IgG antibodies (RBD IgG) and pseudo-virus neutralization assays. Multivariable logistic regression analyses were used to identify factors associated with vaccine-induced antibody response. Adverse events (AEs) were monitored.

FINDINGS

RBD-IgG antibodies were detected in 154/156 (98.7%) of patients with HIV, 75/90 (83.3%) with solid malignancies, 149/187 (79.7%) with myeloma, 83/111 (74.8%) following hematopoietic stem cell transplants, 25/36 (69.4%) following liver transplantation, 26/43 (60.5%) with myelodysplastic syndrome, 96/188 (51.0%) with chronic lymphocytic leukemia/non-Hodgkin's lymphoma, 50/110 (45.5%) following kidney transplantation, 15/80 (18.8%) following heart transplantation, and 269/272 (98.9%) in controls. There was a significant correlation r = 0.74 (95%CI 0.69,0.78) between RBD-binding IgG and neutralizing antibodies in all groups. Multivariate logistic regression analysis showed that age > 65 years (OR 0.41,95%CI 0.30,0.57) and underlying immunosuppression (OR 0.02,95%CI 0.01,0.07) were significantly associated with a non-reactive response of IgG antibodies. HIV patients showed a similar immunological response as healthy adults. The vaccine was safe without any episodes of rejection, graft-versus-host disease (GVHD) or allergy. Immunocompetent HCWs experienced significantly more AEs than ICPs.

INTERPRETATION

Antibody response to the Pfizer-BioNTech vaccine was highly variable among different ICPs; thus, individual recommendations should be provided for the different immunosuppression states.

Efficacy of the mRNA-Based BNT162b2 COVID-19 Vaccine in Patients with Solid Malignancies Treated with Anti-Neoplastic Drugs

The BNT162b2 vaccine was shown to be highly effective in reducing the risk of COVID-19 infection in healthy individuals and patients with chronic disease. However, there are little data regarding its efficacy in patients treated for cancer. We analyzed the humoral response following vaccination with the second dose of BNT162b2 in 140 patients with solid malignancies who were receiving anti-cancer therapy at the time of vaccination and 215 participants who had not been diagnosed with cancer. Multivariate analysis was performed, followed by matching the two groups by age, gender and days from vaccination. The humoral response in the cancer patient group was significantly lower than in the non-cancer group: 20/140 seronegative (14.3%) vs. 3/215 (1.4%), p < 0.001; median IgG levels 2231 AU/mL (IQR 445-8023) vs. 4100 (IQR 2231-6774) p = 0.001 respectively. The odds ratio for negative serology results in cancer patients adjusted by age and gender was 7.35 compared to participants without cancer. This effect was observed only in chemotherapy treated patients: 17/73 seronegative (23.3%) vs. 3/215 (1.4%), p < 0.001; median IgG 1361 AU/mL vs. 4100, p < 0.001 but not in patients treated with non-chemotherapeutic drugs. Reduced immunogenicity to COVID-19 vaccine among chemotherapy-treated cancer patients, raises the need to continue exercising protective measures after vaccination in these patients.

Patterns and association of vaccination among adults with a history of cancer in the USA: a population-based study

Aim: To assess the association of vaccination status among adults with history of cancer in a population-based cohort in the USA. Materials & methods: National Health Interview Survey datasets (2008-2018) have been accessed and information about the patterns and associations of the following vaccinations were collected (influenza vaccination, pneumococcal vaccination, hepatitis B vaccination, hepatitis A vaccination and shingles vaccination). Association of different sociodemographic variables with each of the above types of vaccination was studied through multivariable logistic regression analysis. Results: Private health insurance (vs no private insurance) was associated with higher percentages of recommended vaccination (influenza vaccination: 65 vs 59.7%; pneumococcal vaccination: 74.9 vs 68.8%; hepatitis B vaccination: 22.9 vs 19.3%; hepatitis A vaccination: 10.1 vs 8.6%; shingles vaccination: 33.8 vs 26.7%; p < 0.001 for all comparisons). Within multivariable logistic regression analyses, African American race, lower education and lower income were associated with less probability of adherence to recommended vaccination (for influenza vaccination; odds ratio (OR) for black race vs white race: 0.785; 95% CI: 0.717-0.859; OR for ≤high school vs >high school education: 0.763; 95% CI: 0.723-0.805; OR for income ≤US$45,000 vs >US$45,000: 0.701; 95% CI: 0.643-0.764). Conclusion: There is evidence of socio-economic disparities in adherence to recommended vaccination among this cohort of cancer survivors in the USA. More efforts need to be done to ensure that recommended vaccination is being delivered to all cancer survivors in need (including enhancing coverage and awareness to under-represented groups of the society).

Attitudes of Patients with Cancer towards Vaccinations-Results of Online Survey with Special Focus on the Vaccination against COVID-19

Recently developed COVID-19 vaccines significantly reduce the risk of severe coronavirus disease, which is essential in the particularly vulnerable cancer patient population. There is a growing anti-vaccine concern that may affect the success of the fight against the SARS-CoV2 pandemic. To evaluate opinions and attitudes toward vaccination, we conducted an anonymous online survey among Polish patients diagnosed with cancer. We analyzed how socio-demographic factors, type of cancer, comorbidities, previous influenza vaccinations, and information sources affect the general willingness and opinions about vaccinations, emphasizing vaccination against COVID-19. Six hundred thirty-five patients (80.2% female) participated in the study. A positive attitude towards vaccination was presented by 73.7%, neutral by 17.8%, while negative by 8.5%. Willingness to get vaccinated was declared by 60.3%, 23.5% were unwilling, and 16.2% were undecided. Significant predictors of willingness were education, marital status, active anti-cancer treatment, previous influenza vaccination, and positive attitude towards vaccinations. Patients with cancer have concerns regarding safety, effectiveness, and the process of development of the COVID-19 vaccine. Overall, patients with cancer present positive attitudes towards COVID-19 vaccination but required sufficient information on its efficacy and side effects.

To Vaccinate or not: Influenza Virus and Lung Cancer Progression

Influenza virus infection leads to severe and complicated disease, particularly in patients with lung cancer. It alters the tumor microenvironment (TME), which may potentiate lung cancer progression and disrupt responses to antitumoral treatments. Consequently, influenza vaccination and antiviral treatments should be recommended to all patients with lung cancer.

Covid-19 Vaccination Options for Immunosuppressed Cancer Patients

Background: Currently, many COVID-19 vaccine candidates are being developed to end the pandemic; however, immunosuppressed cancer patients have been excluded from the participating criteria. It is important that they are able to examine their options for achieving immunity against COVID-19. Purpose: This review aims to discuss the available options that can be taken to vaccinate immunosuppressed cancer patients when no vaccine is being developed for their safety. Method: A literature study was conducted using Google Scholar, DOAJ, and GARUDA Library on November 2, 2020, focusing on articles examining vaccination guidelines for immunosuppressed cancer patients. Results: The search found 200 articles, which were curated to obtain 13 articles that satisfied all inclusion criteria. These consist of four guidelines, five reviews, and four research articles. Based on the literature, immunosuppressed cancer patients have the option to use the vaccines currently under development, with precautions set for live attenuated and potentially infectious vaccines. Vaccination timing also needs to be adjusted so as to fall at a certain time before or after the immunosuppressive condition. Moreover, a more complete COVID-19 immunity can be achieved through a synergy between individual vaccination and the construction of herd immunity. Conclusion: Most of the vaccines currently under development may be safe for cancer patients, being mindful of several considerations. Here, herd immunity can serve as a complement to individual immunity.

Surveillance of the current situation regarding influenza vaccination according to medical oncologists in Japan

This study aimed to clarify the attitude of oncologists toward influenza vaccination and the current situation and issues regarding influenza vaccination for patients on chemotherapy in Japan. A web-based survey of medical oncologists certified by the Japanese Society of Medical Oncology was conducted between November 1 and December 31, 2019. Of the 1369 medical oncologists who were invited to participate, 415 (30.3%) responded to our survey. The questionnaire comprised 4 sections: "oncologist characteristics," "oncologist attitude toward influenza vaccines and the current status of influenza vaccination for cancer patients undergoing chemotherapy," "incidence of influenza infection and associated treatment complications," and "treatment policy for influenza infection." In total, 153 (36.9%) physicians replied that they did not actively encourage influenza vaccination for patients undergoing chemotherapy. The primary reasons given were lack of evidence (48/153, 31.4%) and uncertainty of appropriate timing (46/153, 30.1%). There was diverse variation in the timing of vaccination and in the levels of encouragement based on the cancer location and medication type. Two hundred eighty-three (68.2%) oncologists reported that their cancer patients had experienced influenza infection while undergoing chemotherapy, and 169 (40.7%) responded that their patients had experienced an administration delay or discontinuation of medication because of influenza infection. Our surveillance revealed some oncologists considered evidence regarding the administration of influenza vaccine to cancer patients undergoing chemotherapy (particularly the optimal timing and level of recommendation by cancer location and medication) to be lacking. It also exposed the adverse impact of influenza infection in cancer patients.

Prevalence and healthcare utilization of acute respiratory infections among cancer survivors in the United States: a population-based study

Objective: To examine the prevalence and healthcare use of acute respiratory tract infections (RTIs) among cancer survivors in the United States in a population-based cohort.Methods: Medical Expenditure Panel Survey for 2013, 2015, and 2017 was accessed and adults (>20 years) with known status of cancer diagnosis were reviewed. Multivariable logistic regression analysis was then used to examine factors associated with the likelihood of influenza and pneumonia as well as the likelihood of hospitalization secondary to acute RTIs.Results: A total of 75,665 participants were included (including 6397 cancer survivors and 68,733 participants without a cancer history). Within the cohort of cancer survivors, upper RTIs were recorded in 10.6% and influenza and pneumonia were recorded in 7.8%. Within the cohort of cancer survivors, individuals with influenza and pneumonia have a higher total healthcare expenditure (mean: 19,387.59 $ versus 12,714.57 $; P < 0.001) and total out-of-pocket expenditure (mean: 1494.61 $ versus 1159.27 $; P < 0.001). Multivariable logistic regression analysis showed that a history of cancer was associated with a higher likelihood of influenza and pneumonia (OR: 1.119; 95% CI: 1.005-1.247; P = 0.041) as well as hospitalization following acute RTIs (1.586; 95% CI: 1.197-2.103; P = 0.001).Conclusions: Within the studied cohort, cancer Survivors were more likely to be diagnosed with influenza and pneumonia and they were more likely to be hospitalized because of acute RTIs.

Influenza and pneumonia-attributed deaths among cancer patients in the United States; a population-based study

Objective: To assess the patterns and trends of influenza and pneumonia-attributed deaths among cancer patients in the United States.Methods: Surveillance, Epidemiology and End Results (SEER) database was accessed and cancer patients diagnosed 1975-2016 who have been included in the SEER-9 registries were included. The primary endpoint of the study is standardized mortality rate (SMR; calculated as observed/ Expected (O/E) ratio for death from influenza and pneumonia among cancer patients).Results: The current study evaluates a total of 3,579,199 cancer patients (diagnosed 1975-2016) within the SEER-9 registries; and influenza and pneumonia-attributed deaths represent 1.5% of the recorded deaths for this cohort. SMR for influenza/ pneumonia-attributed death within the first year following cancer diagnosis was 1.88 (1.83-1.94);while SMR for influenza/pneumonia-attributed death following the first year was 1.11 (1.10-1.12). Within the first year following cancer diagnosis, SMR from influenza/pneumonia was higher among individuals with black race (SMR for white race: 1.75 (95% CI: 1.69-1.81) while SMR for black race: 2.90 (95% CI: 2.65-3.16), lung cancer (SMR for lung cancer: 4.39 (95% CI: 4.11-4.69)), head and neck cancer (SMR for oral cavity/ pharynx cancer: 4.02 (95% CI: 3.50-4.59)), lymphomas (SMR for lymphoma: 3.28 (95% CI: 2.92-3.68)), leukemias (SMR for leukemia: 3.32 (95% CI: 2.89-3.80)) and myeloma (SMR for myeloma: 3.91 (95% CI: 3.28-4.63)).Conclusions: Cancer patients are more likely to have influenza/ pneumonia-attributed death compared to the general US population. This risk is higher among patients with lung cancer, head and neck cancer, and hematological malignancies.

Influenza in hospitalised patients with malignancy: a propensity score matching analysis

Background

Patients with malignancy are vulnerable to influenza viruses and are at high risk of developing serious complications. However, few studies have investigated the impact of influenza infection among hospitalised patients with malignancy.

Methods

Cancer-related hospitalisations were identified by using data from National Inpatient Sample in the USA between 2012 and 2014. We conducted a 1:1 propensity score matching analysis to compare the in-hospital outcomes between cancer patients with and without influenza. Multivariate logistic regression analyses were also performed to identify independent prognosis predictors of mortality.

Results

We identified 13 186 849 weighted cancer-related hospitalisations during the study period, and 47 850 of them (0.36%) had a concomitant diagnosis of influenza. After propensity score matching, cancer patients with concomitant influenza had a higher mortality (5.4% vs 4.2%; OR, 1.30; 95% CI, 1.13 to 1.49; p<0.001), longer length of stay (6.3 days vs 5.6 days; p<0.001) but lower costs (US$14 605.9 vs US$14 625.5; p<0.001) in hospital than those without influenza. In addition, cancer patients with influenza had a higher incidence of complications, including pneumonia (18.4% vs 13.2%; OR, 1.49; 95% CI, 1.37 to 1.62; p<0.001), neutropenia (7.1% vs 3.4%; OR, 2.18; 95% CI, 1.91 to 2.50; p<0.001), sepsis (19.5% vs 9.3%; OR, 2.36; 95% CI, 2.16 to 2.58; p<0.001), dehydration (14.8% vs 8.8%; OR, 1.80; 95% CI, 1.65 to 1.97; p<0.001) and acute kidney injury (19.9% vs 17.6%; OR, 1.16; 95% CI, 1.08 to 1.25; p<0.001) than those without influenza. Older age, no insurance, more comorbidities, lung cancer and haematological malignancy were independently associated with higher mortality.

Conclusion

Influenza is associated with worse in-hospital clinical outcomes among hospitalised patients with malignancy. Annual influenza vaccination and early initiation of antiviral therapy are recommended in this high-risk population.

Epidemiology, Diagnosis, Treatment, and Prevention of Influenza Infection in Oncology Patients

Influenza infection causes increased morbidity and higher mortality in patients receiving treatment of underlying cancer, particularly in those with hematological malignancy or patients who have undergone hematopoietic stem-cell transplantation. The illness is characterized by seasonality and nonspecific clinical manifestations of upper respiratory infection at a time when other respiratory illnesses are common in the community, making the diagnosis challenging. However, accurate and timely diagnosis by new molecular techniques is crucial in the management of immunocompromised patients, because delays in initiating appropriate therapy can have devastating consequences. Emergence of viral resistance to currently used antiviral agents is of concern, particularly in immunocompromised hosts, and warrants continued monitoring and surveillance. Early and effective treatment improves outcomes, but optimal therapeutic strategies in patients with cancer are not well defined. Health care and research efforts should focus on defining treatment guidelines in patients with cancer and attempt to improve on current vaccination strategies.

Immunological effects of adjuvants in subsets of antigen presenting cells of cancer patients undergoing chemotherapy

Background

We have previously shown that HCC patients and healthy subjects are equally responsive to a RNAdjuvant^®, a novel TLR-7/8/RIG-I agonist based on noncoding RNA developed by CureVac, by an ex vivo evaluation. However, the immunological effect of adjuvants on immune cells from cancer patients undergoing chemotherapy remains to be demonstrated. Different adjuvants currently used in cancer vaccine clinical trials were evaluated in the present study on immune cells from cancer patients before and after chemotherapy in an ex vivo setting.

Methods

PBMCs were obtained from 4 healthy volunteers and 23 patients affected by either colon (OMA) or lung cancer (OT). The effect of CpG, Poly I:C, Imiquimod and RNA-based adjuvant (RNAdjuvant^®) was assessed using a multiparametric approach to analyze network dynamics of early immune responses. Evaluation of CD80, CD86 and HLA-DR expression as well as the downstream effect on CD4⁺ T cell phenotyping was performed by flow cytometry; cytokine and chemokine production was evaluated by Bio-Plex ProTM.

Results

Treatment with RNAdjuvant^® induced the strongest response in cancer patients in terms of activation of innate and adoptive immunity. Indeed, CD80, CD86 and HLA-DR expression was found upregulated in circulating dendritic cells, which promoted a CD4⁺ T cell differentiation towards an effector phenotype. RNAdjuvant^® was the only one to induce most of the cytokines/chemokines tested with a pronounced Th1 cytokine pattern. According to the different parameters evaluated in the study, no clear cut difference in immune response to adjuvants was observed between healthy subjects and cancer patients. Moreover, in the latter group, the chemotherapy treatment did not consistently correlate to a significant altered response in the different parameters.

Conclusions

The present study is the first analysis of immunological effects induced by adjuvants in cancer patients who undergo chemotherapy, who are enrolled in the currently ongoing cancer vaccine clinical trials. The results show that the RNAdjuvant^® is a potent and Th1 driving adjuvant, compared to those tested in the present study. Most importantly, it is demonstrated that chemotherapy does not significantly impair the immune system, implying that cancer patients are likely to respond to a cancer vaccine even after a chemotherapy treatment.

Observational study of vaccination in cancer patients: How can vaccine coverage be improved?

BACKGROUND

Chemotherapy increases the risk of infections, often severe, and some of them are vaccine-preventable infections. We aimed to assess vaccination coverage and associated factors in oncology and hematology patients.

METHODS

Consecutive adult patients followed in a French university hospital for hematological malignancy or solid cancer voluntarily completed an anonymous questionnaire in September and October 2016. It included questions on underlying disease, chemotherapy, flu, and pneumococcal vaccination uptakes, and attitudes toward vaccination. Factors associated with vaccination uptake were assessed by multivariate logistic regression.

RESULTS

The response rate was 41.9% (N=671) among 1,600 questionnaires distributed; 232 patients had underlying hematological malignancy and 439 had solid cancer. Half of the patients were aged over 65 years. Chemotherapy was ongoing or discontinued for less than one year in 74.7% of patients. In patients aged <65 years undergoing chemotherapy, flu vaccination rate was 19.9% whereas patients aged >65 years had coverage of 47%. Pneumococcal vaccine uptake was 7.3%. However, 64.7% of patients were favorable to vaccination. Vaccine uptake was associated with age >65 years (OR 4.5 [2.9-7.0]), information about vaccination delivered by the family physician (OR 12.9 [5.5-30.1]), follow-up in hematology unit (OR 2.0 [1.3-3.1]), and positive opinion about vaccination (OR 2.0 [1.3-3.1]).

CONCLUSION

Despite specific recommendations regarding immunocompromised patients, anti-pneumococcal and flu vaccinations were rarely conducted, even in elderly patients. Targeted information campaigns to family physicians, oncologists, and patients should be implemented to improve vaccine coverage in patients with underlying malignancies.

Mapping Host-Related Correlates of Influenza Vaccine-Induced Immune Response: An Umbrella Review of the Available Systematic Reviews and Meta-Analyses

Seasonal influenza is the leading infectious disease in terms of its health and socioeconomic impact. Annual immunization is the most efficient way to reduce this burden. Several correlates of influenza vaccine-induced protection are commonly used, owing to their ready availability and cheapness. Influenza vaccine-induced immunogenicity is a function of host-, virus- and vaccine-related factors. Host-related factors constitute the most heterogeneous group. The objective of this study was to analyze the available systematic evidence on the host factors able to modify influenza vaccine-induced immunogenicity. An umbrella review approach was undertaken. A total of 28 systematic reviews/meta-analyses were analyzed—these covered the following domains: intravenous drug use, psychological stress, acute and chronic physical exercise, genetic polymorphisms, use of pre-/pro-/symbiotics, previous Bacillus Calmette–Guérin vaccination, diabetes mellitus, vitamin D supplementation/deficiency, latent cytomegalovirus infection and various forms of immunosuppression. In order to present effect sizes on the same scale, all possible meta-analyses were re-performed and cumulative evidence synthesis ranking was carried out. The meta-analysis was conducted separately on each health condition category and virus (sub)type. A total of 97 pooled estimates were used in order to construct an evidence-based stakeholder-friendly map. The principal public health implications are discussed.

Influenza Vaccine Effectiveness Among Patients With Cancer: A Population-Based Study Using Health Administrative and Laboratory Testing Data From Ontario, Canada

PURPOSE

Seasonal influenza vaccination is recommended for patients with cancer despite concerns of disease or treatment-associated immunosuppression. The objective of this study was to evaluate vaccine effectiveness (VE) against laboratory-confirmed influenza for patients with cancer.

PATIENTS AND METHODS

We conducted an observational test-negative design study of previously diagnosed patients with cancer 18 years of age and older who underwent influenza testing during the 2010-2011 to 2015-2016 influenza seasons in Ontario, Canada. We linked individual-level cancer registry, respiratory virus testing, and health administrative data to identify the study population and outcomes. Vaccination status was determined from physician and pharmacist billing claims. We used multivariable logistic regression to estimate VE, adjusting for age, sex, rurality, income quintile, cancer characteristics, chemotherapy exposure, comorbidities, previous health care use, influenza season, and calendar time.

RESULTS

We identified 26,463 patients with cancer who underwent influenza testing, with 4,320 test-positive cases (16%) and 11,783 (45%) vaccinated. Mean age was 70 years, 52% were male, mean time since diagnosis was 6 years, 69% had solid tumor malignancies, and 23% received active chemotherapy. VE against laboratory-confirmed influenza was 21% (95% CI, 15% to 26%), and VE against laboratory-confirmed influenza hospitalization was 20% (95% CI, 13% to 26%). For patients with solid tumor malignancies, VE was 25% (95% CI, 18% to 31%), compared with 8% (95% CI, -5% to 19%) for patients with hematologic malignancies (P = .015). Active chemotherapy usage did not significantly affect VE, especially among patients with solid tumor cancer.

CONCLUSION

Our results support recommendations for influenza vaccination for patients with cancer. VE was decreased for patients with hematologic malignancies, and there was no significant difference in VE among patients with solid tumor cancer receiving active chemotherapy. Strategies to optimize influenza prevention among patients with cancer are warranted.

Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors

Background

Influenza vaccination (FV) is recommended for patients with cancer. Recent data suggested that the administration of the FV was associated with an increase in immune-related adverse events (irAEs) among patients on immune checkpoint inhibitors (ICIs). Myocarditis is an uncommon but serious complication of ICIs and may also result from infection with influenza. There are no data testing the relationship between FV and the development of myocarditis on ICIs.

Methods

Patients on ICIs who developed myocarditis (n = 101) (cases) were compared to ICI-treated patients (n = 201) without myocarditis (controls). A patient was defined as having the FV if they were administered the FV from 6 months prior to start of ICI to anytime during ICI therapy. Alternate thresholds for FV status were also tested. The primary comparison of interest was the rate of FV between cases and controls. Patients with myocarditis were followed for major adverse cardiac events (MACE), defined as the composite of cardiogenic shock, cardiac arrest, hemodynamically significant complete heart block and cardiovascular death.

Results

The FV was administered to 25% of the myocarditis cases compared to 40% of the non-myocarditis ICI-treated controls (p = 0.01). Similar findings of lower rates of FV administration were noted among myocarditis cases when alternate thresholds were tested. Among the myocarditis cases, those who were vaccinated had 3-fold lower troponin levels when compared to unvaccinated cases (FV vs. No FV: 0.12 [0.02, 0.47] vs. 0.40 [0.11, 1.26] ng/ml, p = 0.02). Within myocarditis cases, those administered the FV also had a lower rate of other irAEs when compared to unvaccinated cases (36 vs. 55% p = 0.10) including lower rates of pneumonitis (12 vs. 36%, p = 0.03). During follow-up (175 [IQR 89, 363] days), 47% of myocarditis cases experienced a MACE. Myocarditis cases who received the FV were at a lower risk of cumulative MACE when compared to unvaccinated cases (24 vs. 59%, p = 0.002).

Conclusion

The rate of FV among ICI-related myocarditis cases was lower than controls on ICIs who did not develop myocarditis. In those who developed myocarditis related to an ICI, there was less myocardial injury and a lower risk of MACE among those who were administered the FV.

Electronic supplementary material

The online version of this article (10.1186/s40425-019-0535-y) contains supplementary material, which is available to authorized users.

Immune-checkpoint inhibitors in non-small cell lung cancer: A tool to improve patients' selection

The identification of reliable predictive biomarkers of efficacy or resistance to immune-oncology (I-O) agents is a major issue for translational research and clinical practice. However, along with PDL1 and molecular features other clinical, radiological and laboratory factors can be considered for the selection of those patients who would not be the best candidate for immune-checkpoint inhibitors (ICPIs). We examined these factors, emerging from the results of currently available studies in non-small cell lung cancer (NSCLC), aiming to provide a useful and manageable tool which can help Oncologists in their everyday clinical practice. A thorough patient evaluation and close clinical monitoring, due to limited, early or inconclusive currently available data, should be deserved for patients with a pre-existing symptomatic chronic obstructive pulmonary disease, age >75 years, Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥ 1, a time to progression (TTP) < three months and progressive disease (PD) as the best response to the previous treatment, hepatitis or HIV-infections, high neutrophil to lymphocyte ratio (NLR), or on treatment with high-dose steroids, when the use of ICPIs is considered. Limited data are available to consider that ICPIs are safe in patients with interstitial lung disease, bronchiolitis obliterans organizing pneumonia and autommune diseases. Early evidence on steroids, vaccinations and antibiotics suggest their possible interaction with ICPIs and need to be more investigated in clinical trials. Oncogene-addicted NSCLC harboring EGFR-mutations and low tumor-infiltrating T-lymphocytes (TILs) seems not to gain benefit from I-O.

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.