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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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Wohlschlaeger A, Levy E, Khan RN, Heimall J, Fisher BT, Metjian TA, Elgarten CW, Freedman JL. A Retrospective Review of Revaccination Patterns in Pediatric Hematopoietic Stem Cell Transplantation Recipients. JOURNAL OF PEDIATRIC HEMATOLOGY/ONCOLOGY NURSING 2023; 40:259-264. [PMID: 37069829 DOI: 10.1177/27527530221147861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
Background: After a hematopoietic stem cell transplantation (HSCT), patients are left with little to no immunity to prevent infections. Importantly, this includes immunity gained from previous exposures, including vaccinations. This loss of immunity is a direct result of previous chemotherapy, radiation, and conditioning regimens the patients receive. It is critical to revaccinate patients post-HSCT to ensure protective immunity against vaccine-preventable diseases. Before 2017, all patients at our institution were referred to their pediatrician at approximately 12-month post-HSCT to be revaccinated. Clinical concern was raised at our institution regarding nonadherence and errors in vaccine schedules. Methods: To understand the magnitude of the problem with revaccination, we performed an internal audit of post-vaccine adherence in patients who received an HSCT between 2015 and 2017. A multidisciplinary team was developed to review the audit results and make recommendations. Results: This audit revealed delays in the initiation of the vaccine schedule, incomplete adherence to the recommended revaccination schedule, and errors in administration. Discussion: Based on the review of the data, the multidisciplinary team recommended an approach for systematic assessment of vaccine readiness and centralization of the administration of vaccines to be done within the stem cell transplant outpatient center.
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Affiliation(s)
- Anne Wohlschlaeger
- Blood and Marrow Transplant, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ellen Levy
- Infectious Disease and Vaccines, Merck Pharmaceuticals, North Wales, PA, USA
| | - Raabia N Khan
- Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Heimall
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brian T Fisher
- Pediatrics and Epidemiology, Robert's Pediatric Research Center, Philadelphia, PA, USA
| | - Talene A Metjian
- Antimicrobial Stewardship Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Caitlin W Elgarten
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jason L Freedman
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Zhang L, Thornton CP, Ruble K, Cooper SL. Post-Chemotherapy Titer Status and Need for Revaccination After Treatment for Childhood Cancer. Clin Pediatr (Phila) 2020; 59:606-613. [PMID: 32423345 DOI: 10.1177/0009922820915884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objectives. To evaluate the strategy of checking vaccine titers after completion of chemotherapy. Study Design. Retrospective review of pediatric oncology patients who completed chemotherapy. Demographics, post-chemotherapy titers, and absolute lymphocyte counts (ALCs) were analyzed. Results. Ninety patients met inclusion criteria, and 87% of patients had at least one titer checked. Comparing patients <7 years and those ≥7 years at diagnosis, there was no difference in incidence of negative titers except mumps; those <7 years old were more likely to have negative titers (58% vs 20%, P = .003). Comparing those <13 years old to ≥13 years old, there was no difference in negative titers except mumps (45% vs 19%, P = .02) and tetanus (44% vs 0%, P = .002). No patient maintained all protective titers after completion of chemotherapy. Time to ALC recovery was not predictive of positive titers. Conclusion. Checking titers after chemotherapy is not recommended. Providers should assume loss of immunity.
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Affiliation(s)
- Lindy Zhang
- Johns Hopkins University, Baltimore, MD, USA.,National Institutes of Health, Bethesda, MD, USA
| | - Clifton P Thornton
- Johns Hopkins University, Baltimore, MD, USA.,Herman & Walter Samuelson Children's Hospital at Sinai, Baltimore, MD, USA
| | - Kathy Ruble
- Johns Hopkins University, Baltimore, MD, USA
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Immunization of Children with Cancer in India Treated with Chemotherapy — Consensus Guideline from the Pediatric Hematology-Oncology Chapter and the Advisory Committee on Vaccination and Immunization Practices of the Indian Academy of Pediatrics. Indian Pediatr 2019. [DOI: 10.1007/s13312-019-1678-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Pediatric oncology patients treated with antineoplastic therapy have impaired immune systems that lead to loss of protective antibodies. They require reimmunization to protect against vaccine-preventable diseases. There are a paucity of studies on the clinical practice of pediatric oncologists and the available recommendations are heterogenous. This study describes current reimmunization practices among pediatric oncologists. We surveyed the Children's Oncology Group (COG)-identified principle investigators to capture clinical practices among pediatric oncologists within their institutions regarding reimmunization of non-hematopoietic stem cell transplantation patients. The majority of respondents did not routinely assess vaccine-related immune status; those who did most frequently assessed 6 months after cessation of therapies. Methods of assessment included type of therapy received, vaccine titers, and absolute lymphocyte counts. Providers from smaller institutions were more likely to check vaccine titers than those from larger institutions. More than half of the surveyed institutions did not have standardized guidelines available for practitioners. There are variations in reimmunization practices among pediatric oncologists despite available guidelines on recommended schedules. Further research is needed to identify the safest and most cost-effective way to insure immunity to infectious disease after the treatment of childhood cancer.
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de de la Fuente Garcia I, Coïc L, Leclerc JM, Laverdière C, Rousseau C, Ovetchkine P, Tapiéro B. Protection against vaccine preventable diseases in children treated for acute lymphoblastic leukemia. Pediatr Blood Cancer 2017; 64:315-320. [PMID: 27718310 DOI: 10.1002/pbc.26187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/04/2016] [Accepted: 07/06/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND The objective of this retrospective study was to assess protection against vaccine preventable diseases (VPDs) in children treated for acute lymphoblastic leukemia (ALL). PROCEDURE Clinical characteristics and vaccination records were collected. Antibodies against VPDs were measured after completion of chemotherapy and after a booster dose of vaccine. Immunization status of household members was evaluated. RESULTS Sixty children were included. Median interval between the end of chemotherapy and enrolment in the study was 13 months (range 1-145). At ALL diagnosis, 81.3% of the children were up to date with their vaccination schedule. This proportion decreased to 52.9% at enrolment. Among the parents, 21% were up to date with their immunization schedule and 42% had received seasonal influenza vaccination. After chemotherapy, less than 50% of the patients were seroprotected against tetanus, diphtheria, polio 3, Haemophilus influenzae type b (Hib), and mumps and no more than 80% were seroprotected against polio 1 and 2, measles, rubella, and varicella. After a booster dose of vaccine, the rate of protection increased to over 90% for each of the following antigens: TT, DT, polio 1, Hib, measles, and rubella. Nevertheless, polio 3, mumps, and varicella-zoster virus antibodies titers/concentrations remained below seroprotective thresholds in over 20% of the patients. CONCLUSIONS After chemotherapy for ALL, most of the children were not protected against VPDs. As the majority mounted a robust response to booster vaccines, efforts need to be done to improve protection against VPDs by implementing a systematic vaccine booster schedule. This could also be helped by reinforcing household members' immunization.
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Affiliation(s)
- Isabel de de la Fuente Garcia
- Division of Infectious Diseases, Department of Pediatrics, CHU Sainte-Justine-Université de Montréal, Montréal, Québec, Canada
| | - Léna Coïc
- Division of Infectious Diseases, Department of Pediatrics, CHU Sainte-Justine-Université de Montréal, Montréal, Québec, Canada
| | - Jean-Marie Leclerc
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine-Université de Montréal, Montréal, Québec, Canada
| | - Caroline Laverdière
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine-Université de Montréal, Montréal, Québec, Canada
| | - Céline Rousseau
- Department of Microbiology and Immunology, CHU Sainte-Justine-Université de Montréal, Montréal, Québec, Canada
| | - Philippe Ovetchkine
- Division of Infectious Diseases, Department of Pediatrics, CHU Sainte-Justine-Université de Montréal, Montréal, Québec, Canada
| | - Bruce Tapiéro
- Division of Infectious Diseases, Department of Pediatrics, CHU Sainte-Justine-Université de Montréal, Montréal, Québec, Canada
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Arora RS, Prabha S, Roy Moulik N, Bagai P. A survey of immunization practices in children with cancer in India. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2016. [DOI: 10.1016/j.phoj.2016.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Bauters T, Bordon Cueto De Braem V, Schelstraete P, Van Lancker S, Laureys G, Benoit Y, Dhooge C. Evaluation of timing of first vaccination in children after hematopoietic allogeneic stem cell transplantation. Eur J Oncol Nurs 2015; 21:212-4. [PMID: 26645948 DOI: 10.1016/j.ejon.2015.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 09/03/2015] [Accepted: 10/26/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Protective immunity to vaccine preventable infectious diseases might be lost over time following hematopoietic stem cell transplantation (HSCT). Limited data are available on the appropriate follow-up of vaccination schedules in pediatric HSCT patients. This study aims to ascertain whether the guidelines for vaccination recommended in our hospital are followed and to which extent of conformity they are used. METHODS A 5-year survey, including all pediatric allogeneic HSCT patients, transplanted at the Ghent University hospital, Belgium. Data were collected from the patient's electronic (nursing and medical) charts. RESULTS Data on vaccination schedules of 28 patients (54.9%) eligible for the recommended vaccinations were collected. Eleven patients (11/28; 39.3%) were vaccinated timely. In 14 out of 17 patients (82.4%) vaccination was postponed for medical reasons, while vaccination was postponed without medical reason in 17.6% (3/17). Vaccination data could not be retrieved in 43.1 (22/51) of patients. Vaccination was declined by the parents in one patient (2.0%). CONCLUSION There is high level of agreement between the hospital guideline and the vaccination of pediatric HSCT patients. Health-care providers play a crucial role in effectively appropriate follow-up of vaccination schedules.
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Affiliation(s)
- Tiene Bauters
- Department of Pediatric Hemato-Oncology and Hematopoietic Stem Cell Transplantation, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium.
| | - Victoria Bordon Cueto De Braem
- Department of Pediatric Hemato-Oncology and Hematopoietic Stem Cell Transplantation, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Petra Schelstraete
- Department of Pediatric Pulmonology and Infectious Diseases, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Sophie Van Lancker
- Department of Pediatric Hemato-Oncology and Hematopoietic Stem Cell Transplantation, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Geneviève Laureys
- Department of Pediatric Hemato-Oncology and Hematopoietic Stem Cell Transplantation, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Yves Benoit
- Department of Pediatric Hemato-Oncology and Hematopoietic Stem Cell Transplantation, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Catharina Dhooge
- Department of Pediatric Hemato-Oncology and Hematopoietic Stem Cell Transplantation, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
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Mellado Peña M, Ruiz Contreras J, Moreno Pérez D, Navarro Gómez M. Documento de Consenso de la Sociedad Española de Infectología Pediátrica y el Comité Asesor de Vacunas de la Asociación Española de Pediatría para la vacunación en inmunodeprimidos. Respuesta de los autores. An Pediatr (Barc) 2012. [DOI: 10.1016/j.anpedi.2012.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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van Tilburg CM, Bierings MB, Berbers GAM, Wolfs TFW, Pieters R, Bloem AC, Sanders EAM. Impact of treatment reduction for childhood acute lymphoblastic leukemia on serum immunoglobulins and antibodies against vaccine-preventable diseases. Pediatr Blood Cancer 2012; 58:701-7. [PMID: 21793184 DOI: 10.1002/pbc.23258] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 06/06/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND The consequences of current intensive chemotherapy for childhood acute lymphoblastic leukemia (ALL) for immune defense are a matter of concern. The purpose of this study was to examine the effect of reduced compared with intensive (conventional) ALL chemotherapy on serum immunoglobulin levels and specific antibody concentrations against vaccine-preventable diseases. PROCEDURE Patients treated according to Dutch Childhood Oncology Group ALL 10 protocol were stratified by minimal residual disease to receive reduced (standard risk; SR) or intensive (medium risk; MR) intensification/maintenance treatment. Between November 2004 and July 2009 we compared serum immunoglobulins of 110 patients and specific antibodies against diphtheria toxin, tetanus toxin, and Bordetella pertussis antigens of 41 patients of SR and MR groups during chemotherapy. RESULTS Immunoglobulin levels showed significantly different patterns between the SR and MR groups. In the MR group IgG, IgA, and IgM levels decreased towards the end of intensive treatment; in the SR group IgG levels increased while IgA and IgM stabilized. In both groups IgM and IgG levels were most affected. Specific antibody levels against vaccine-preventable diseases decreased in both groups, but more profound in MR group. CONCLUSIONS Although reduced chemotherapy is beneficial for immunoglobulin level recovery and might prevent susceptibility for infections, specific antibodies remain decreased.
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Affiliation(s)
- Cornelis M van Tilburg
- Department of Pediatric Hematology/Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Abstract
In summary, immunizations in special populations require understanding the underlying disease and how it might affect the immune system's ability to mount an antibody response to vaccines or predispose certain patient populations to developing certain serious infections. There is still a great need for research on the optimal timing of vaccines after transplants, how to assess protection and development of a protective antibody response after immunization, and whether certain groups (eg, HIV) need to be revaccinated after a certain amount of time if their antibody levels decline. In addition, there are limited data on efficacy of the newer vaccines in these special patient populations, which also requires further investigation.
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Affiliation(s)
- Michael A Miller
- Department of Pediatric Infectious Diseases and Immunology, University of Florida, Jacksonville, 32209, USA
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Ruggiero A, Battista A, Coccia P, Attinà G, Riccardi R. How to manage vaccinations in children with cancer. Pediatr Blood Cancer 2011; 57:1104-8. [PMID: 21953691 DOI: 10.1002/pbc.23333] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 08/08/2011] [Indexed: 11/07/2022]
Abstract
The optimal use of routine childhood immunizations in children with malignancy is still a matter of debate. Despite their higher risk of contracting vaccine preventable diseases and of suffering important complications, there is little understanding of the magnitude of the possible benefit of administering active immunization in this population due to a paucity of clinical trial data. Our review focuses on the management of children with cancer and offers some suggestions regarding their vaccination schedules.
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Affiliation(s)
- Antonio Ruggiero
- Pediatric Oncology Division, A Gemelli Hospital, Catholic University, Rome, Italy.
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Mellado Peña M, Moreno-Pérez D, Ruíz Contreras J, Hernández-Sampelayo Matos T, Navarro Gómez M. Documento de consenso de la Sociedad Española de Infectología Pediátrica y el Comité Asesor de Vacunas de la Asociación Española de Pediatría para la vacunación en inmunodeprimidos. An Pediatr (Barc) 2011; 75:413.e1-22. [DOI: 10.1016/j.anpedi.2011.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Accepted: 06/14/2011] [Indexed: 11/29/2022] Open
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Abstract
There is little known about the impact of the timing of influenza vaccine administration on seroconversion in patients on chemotherapy. Recommendations for other vaccines state that the vaccines should be readministered several months after the completion of chemotherapy outside of the stem cell transplant setting. This is not often possible with the influenza vaccine because of its seasonal nature. To examine whether certain times during chemotherapy are more favorable for seroconversion, we examined vaccine responses in a cohort of children on chemotherapy. Pediatric patients on chemotherapy were recruited over the 2006 to 2008 influenza vaccine seasons. Sixty-eight acute lymphoblastic leukemia (ALL), 3 acute myeloid leukemia, and 18 sarcoma patients were evaluated. Clinical and laboratory features were recorded. The hemagglutination inhibition (HAI) assay was used to define serotype-specific responses. Seroconversion rates varied according to the type of chemotherapy during the vaccination period. In some cases, there was a late rise in titer, suggesting that a wild-type infection had occurred, leading to an estimate of vulnerability of this population. In patients with ALL, responses to the vaccine were greater when it was given early in the course of treatment. We conclude that seroconversion rates are well below the rates cited for the general population. The 3 acute myeloid leukemia patients had a particularly poor response to the vaccine. In the case of ALL patients, it may be possible to adjust the timing of the vaccine to optimize the response.
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Grabenstein JD, Straus WL, Feinberg MB. Vaccines and vaccination. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00003-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Naqvi A, Fadoo Z, Alvi S. Vaccination guidelines for children with cancer and hematopoietic stem cell transplantation living in resource-poor countries. Pediatr Blood Cancer 2010; 54:3-7. [PMID: 19533656 DOI: 10.1002/pbc.22130] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
There is no consensus on the immunization guidelines for immunocompromised children. Some recommendations are, however, available for children living in developed countries. The spectrum of infectious diseases is different in resource-poor countries. Vaccinations against some of these infections are not a part of the immunization schedule for children living in developed countries. We have tried to include vaccinations against diseases, which are still prevalent and a major cause of morbidity and mortality in resource-poor countries. In these guidelines, the focus has been on the vaccine-preventable diseases prevalent in Pakistan but the same can be applied to other resource-poor countries.
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Affiliation(s)
- Ahmed Naqvi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
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