Measles, mumps, and rubella antibody status and response to immunization in children after therapy for acute lymphoblastic leukemia

Seroprevalence of Measles (Rubeola) Antibodies in Childhood Cancer Survivors

Background: Measles is reemerging as a public health threat, raising important questions about disease vulnerability among childhood cancer survivors. This secondary analysis assessed the seroprevalence of anti-measles immunoglobulin G (IgG) antibodies as a marker of immune status in survivors of childhood cancer and associated demographic/treatment variables. Method: Participants were childhood cancer survivors who were free of active disease, having routine blood studies drawn, and could provide documentation of having received two doses of measles, mumps, and rubella vaccine before their cancer diagnosis. Patient record review documented demographic and treatment variables. Antimeasles (rubeola) IgG antibody seroprevalence was assessed by enzyme immunoassay for vaccine-specific antibodies. Results: Of 270 survivors evaluated, 110 (42%) were female, 196 (75%) were White, and 159 (61%) were leukemia/lymphoma survivors. Of these 262, 110 (42%) had negative measles seroprevalence, suggesting loss of immunity. Conclusion: Measles antibody surveillance and the need for reimmunization for survivors of childhood cancer survivors outside the transplant setting remains controversial. Our analysis indicates that a substantial proportion of survivors lose vaccine-related immunity to measles. Pediatric oncology nurses play important roles in educating cancer survivors regarding their risk of measles infection, evaluating the need for reimmunization, correcting misinformation about vaccine safety and effectiveness, and working to optimize community herd-based immunity.

Measles, mumps, and rubella revaccination in children after completion of chemotherapy and hematopoietic stem cell transplantation: a single-center prospective efficacy and safety analysis

BACKGROUND

Chemotherapy and hematopoietic stem cell transplantation (HSCT) can damage the immune system, and may result in a loss of protection from infectious diseases. This study aimed to evaluate the impact of these treatments on the decrease in antibody titers of the measles, mumps, and rubella (MMR) vaccine and seroconversion post-revaccination of MMR.

METHODS

After completion of treatment for primary diseases, participants received an MMR revaccination. Antibody titers for MMR before revaccination were analyzed for all 110 children. After revaccination, 68 participants received a follow-up evaluation of  antibody titer and adverse reaction.

RESULTS

Multivariable analysis showed that therapeutic schedules were the only factor correlated with lack of antibody titers for measles after completing treatment (P = 0.008), while for mumps and rubella, no statistically significant difference was observed. Importantly, our study clearly demonstrated positive seroconversion rates for measles (97.5%), mumps (81.0%), and rubella (93.2%), with antibody levels rising across the board and peaking at around 6 months following revaccination. However, 6 months after revaccination, a downtrend of antibody titer levels was observed, which is comparatively earlier than the waning immunity observed in healthy children. Furthermore, we found MMR revaccination to be safe, with only a single adverse reaction (local pain at the injection site) reported.

CONCLUSIONS

MMR revaccination is immunogenic for the population. We suggest periodic monitoring of antibody titers, in addition to a booster vaccination, although the optimal timing of booster vaccination remains to be investigated further.

Assessment of Humoral Immunity to Measles Virus in Cancer Survivor Children after Chemotherapy: A Case-Control Study

This case-control study was conducted to determine the antibody titer against the measles virus in childhood cancer survivors' post-chemotherapy treatment to determine the patient's immune status against the measles virus. We enrolled 38 children who were in complete remission and whose treatments had been stopped for at least 3 months and 38 age and sex-matched healthy controls. We analyzed the medical records of the cancer survivors, and each study participant's serum sample was analyzed by the ELISA method to determine the antibody titer against measles. The cancer survivors had significantly lower measles antibody titers than the healthy control participants, and 78.9% of cancer survivors were unprotected (seronegative) compared to 7.9% in healthy controls. After multivariate analysis, there was no statistically significant factor associated with loss of protective humoral immunity against measles. These results underline the need for post-chemotherapy measles antibody testing and revaccination of seronegative survivors.

Immunization status and re-immunization of childhood acute lymphoblastic leukemia survivors

Intensive chemotherapy can cause long-lasting immunosuppression in children who survived cancer. The immunosuppression varies according to the type of cancer, intensity of chemotherapy and age of the patient. A sufficient immune reconstruction when has been completed in childhood cancer survivors, the re-vaccination program can achieve sufficient antibody levels for some of the life-threatening vaccine-preventable infectious diseases. This study evaluates the serological status of pediatric acute lymphoblastic leukemia (ALL) cases before and after the intensive chemotherapy treatment. Antibodies against measles, mumps, rubella, varicella, hepatitis A and B were tested with the enzyme-linked immunosorbent assay (ELISA) method. Antibody titers were measured firstly at the leukemia diagnosis time when the chemotherapy was not started. The second evaluation of antibody titers was studied at 6 months after the cessation of chemotherapy for all patients. Forty-six patients with the mean age of 6.1 ± 4.5 years were participated in this study. Changing to seronegative after treatment was significantly different in measles, rubella, hepatitis A and hepatitis B (p < .05). Seventy-eight (28%) antibody levels in the patients were non-protective for all diseases. Only three (7%) patients had protective antibody levels for all diseases in the sixth month of chemotherapy cessation. There was a negative correlation between patient's age and losing protective antibody levels for any vaccine-preventable disease (p < .05). Antibody levels against vaccine-preventable diseases have evident that reduced after ALL treatment at childhood. Pediatric ALL survivors must be re-vaccinated for vaccine-preventable diseases after achieving immune reconstruction.

Severe infections following treatment for childhood cancer: a report from CYP-C

Little is known about infections occurring after childhood cancer treatment. We assessed the risk of severe infection postcancer therapy in survivors of leukemia compared to other cancer types. We performed a population-based cohort study of children <15 years of age diagnosed with cancer (2001-2016), alive and relapse-free 30 days after treatment completion. The risk of severe infection in both groups was estimated using subdistribution proportional hazard regression. We identified 6148 survivors (1960 with leukemia). The cumulative incidence (95% confidence interval) of severe infections at 3 years was 0.70% (0.40-1.2%) in leukemia and 0.51% (0.32-0.79%) in other cancers. The risk of severe infection was not statistically different in leukemia survivors compared to other cancer types in univariate and multivariate analysis (adjusted hazard ratio: 1.40, 95% CI: 0.69-2.85). No significant association was found between a history of leukemia and an increased risk of severe infection after treatment, compared to other cancer types.

Long-Term Risk of Infections After Treatment of Childhood Leukemia: A Population-Based Cohort Study Using Administrative Health Data

PURPOSE

Infections are a frequent complication during childhood leukemia treatment. Little is known about the infectious risk in survivors. We compared the relative rate (RR) of infections after treatment completion between pediatric leukemia survivors and the general population.

METHODS

We performed a retrospective, population-based cohort study of children diagnosed with leukemia between 1992 and 2015 in Ontario, Canada, who were alive and relapse free 30 days after treatment completion (index date). Leukemia survivors were matched 5:1 with the general population by year of birth, sex, and rural status and stratified by initial treatment, including and excluding hematopoietic stem-cell transplantation (HSCT). The primary outcome was time to infections, as identified using validated diagnostic codes from administrative databases. Individuals were censored at the earliest of death, first relapse, loss to follow-up, or end of study.

RESULTS

A total of 2,204 leukemia survivors were included and matched with 11,020 controls. The rate of infections was elevated after treatment completion compared with controls (RR, 1.51; 95% CI, 1.45 to 1.57) and at less than 1 year (RR, 1.77; 95% CI, 1.69 to 1.86); 1 to 4.99 years (RR, 1.66; 95% CI, 1.62 to 1.71), and 5 or more years (RR, 1.29; 95% CI, 1.22 to 1.36) from the index date. Among those whose initial treatment excluded HSCT, the rate remained elevated more than 5 years from the index date (RR, 1.29; 95% CI, 1.23 to 1.35). Infection-related death was significantly increased in leukemia survivors both among the entire cohort (hazard ratio, 149.3; 95% CI, 20.4 to 1,091.9) and among those without HSCT (hazard ratio, 92.7; 95% CI, 12.4 to 690.7).

CONCLUSION

A significant association was found between a history of leukemia therapy and an increased risk of infections. Additional study is needed to establish which exposures in patients with leukemia lead to late infections.

Preventing Measles in Immunosuppressed Cancer and Hematopoietic Cell Transplantation Patients: A Position Statement by the American Society for Transplantation and Cellular Therapy

Until recently, measles exposures were relatively rare and so, consequently, were an afterthought for cancer patients and/or blood and marrow transplant recipients and their providers. Declines in measles herd immunity have reached critical levels in many communities throughout the United States due to increasing vaccine hesitancy, so that community-based outbreaks have occurred. The reemergence of measles as a clinical disease has raised serious concerns among immunocompromised patients and those who work within the cancer and hematopoietic cell transplantation (HCT) community. Since live attenuated vaccines, such as measles, mumps, and rubella (MMR), are contraindicated in immunocompromised patients, and with no approved antiviral therapies for measles, community exposures in these patients can lead to life-threatening infection. The lack of data regarding measles prevention in this population poses a number of clinical dilemmas. Herein specialists in Infectious Diseases and HCT/cellular therapy endorsed by the American Society of Transplant and Cellular Therapy address frequently asked questions about measles in these high-risk cancer patients and HCT recipients and provide expert opinions based on the limited available data.

Humoral immune response of childhood acute lymphoblastic leukemia survivors against the measles, mumps, and rubella vaccination

BACKGROUND

There is a great risk of infection with viral-vaccine-preventable diseases like measles, mumps, and rubella (MMR) infections after the end of chemotherapy treatment of children with acute lymphoblastic leukemia (ALL), which could have been prevented with MMR vaccination. Previous studies reported widely variable rates of seropositivity (seroprotection) for MMR after ALL treatment ends. Also, few studies evaluated the response to MMR booster vaccinations after the end of ALL treatment and reported unclear and difficult to interpret results.

MATERIAL AND METHODS

This retrospective cross-sectional study evaluated the prevalence of seropositive (protection) antibody titer levels for MMR among ALL childhood survivors who were followed-up at Jeddah Oncology Center, Saudi Arabia. The aim of the study was also to investigate and analyze the response of seronegative patients to a booster MMR vaccination.

RESULTS

Fifty-seven ALL children were evaluated. Thirty-five patients (61.4%) were seropositive/seroprotected and the remaining 22 patients (38.6%) were seronegative for MMR. ALL Children under the age of 5 years had a higher prevalence of seronegative titers. Interestingly, the prevalence of seroprotection decreased as the time interval increased post-treatment, while seroconversion rates after administering a booster MMR vaccine were 57.1%, 87.5%, and 78.6%, respectively for MMR.

CONCLUSION

We suggest the need for booster MMR vaccination, especially for ALL children under the age of 5 years and those who experienced a protracted time interval post-treatment.

Assessment of Humoral Immunity to Hepatitis B, Measles, Rubella, and Mumps in Children After Chemotherapy

BACKGROUND

Cancer survival rates and longevity of patients after therapy have significantly improved during the last few decades. Therefore, lasting protection against infections should be provided.

PROCEDURE

A total of 162 children diagnosed with acute lymphoblastic leukemia, acute myelogenous leukemia, solid tumors, non-Hodgkin lymphoma, and Hodgkin lymphoma were enrolled in the study. Antibody levels against hepatitis B virus was assessed both at the time of diagnosis and within 6 months after completion of chemotherapy. However, measles, mumps, and rubella (MMR) antibodies levels were measured just within 6 months after completion of chemotherapy.

RESULTS

Anti-HBs antibody titers had decreased below the protective level after treatment in 25 of 96 patients having protective antibody levels for hepatitis B virus before therapy. In 66 patients without pretreatment protective levels of antibody, in spite of the immunization during chemotherapy, only 6 of them were found to be anti-HBS positive after treatment. In 153 patients previously vaccinated with MMR, 19 had protective antibody titers after treatment. MMR seropositivities were negatively correlated to age as expected.

CONCLUSIONS

Our data demonstrate that a significant number of children lose preexisting humoral immunity against MMR and hepatitis B after completion of chemotherapy.

Assessment of immune response following immunization with DTP/Td and MMR vaccines in children treated for acute lymphoblastic leukemia

BACKGROUND

This study was performed to determine the antibody titers against diphtheria-tetanus-pertussis, and measles-mumps-rubella before and after re-vaccination in different periods of time in patients with acute lymphoblastic leukemia (ALL) to provide a suitable vaccination schedule.

METHODS

Ninety patients with ALL were studied in three stages, including newly diagnosed patients, patients on maintenance therapy, and 1 to 12 months after cessation of therapy. Baseline antibody titers were assessed in all participants. Postimmunization antibody titers to DTP/Td and MMR vaccines were evaluated 3 weeks after vaccination.

RESULTS

Patients on maintenance therapy had considerable decreased in seropositivity rate; they achieved seroconversion rate of 100% for diphtheria and tetanus and of 71.4% for pertussis following DTP/Td vaccination. In patients after one month off therapy, the seroconversion rates for diphtheria, tetanus, and pertussis were 71.4%, 80%, and 100%, respectively. The amounts of seroconversion in patients after 3 months off therapy were 66.5%, 80%, and 66.5% for measles, mumps, and rubella, respectively. In patients after 6 months off therapy, the seroconversion rates were 85.7% for diphtheria, 100% for pertussis and tetanus, 83.3% for mumps, 50% for rubella, and 41.6% for measles. Patients after 12 months off therapy achieved seroconversion rate of 100% for diphtheria, tetanus, pertussis, and mumps, of 71.5% for rubella, and of 63.5% for measles.

CONCLUSION

Administration of one dosage of DTP/Td vaccine during maintenance therapy and after cessation of therapy could be recommended, while one dosage of MMR vaccine at least three months after completion of therapy could be safe and beneficial.

Antibody responses to Hepatitis B and measles-mumps-rubella vaccines in children who received chemotherapy for acute lymphoblastic leukemia

Objective

To evaluate viral vaccine antibody levels in children with acute lymphoblastic leukemia after chemotherapy and after vaccine booster doses.

Methods

Antibody levels against hepatitis B, rubella, measles and mumps vaccine antigens were evaluated in 33 children after completing chemotherapy (before and after vaccine booster doses) and the results were compared to the data of 33 healthy children matched for gender, age and social class.

Results

After chemotherapy, 75.9%, 67.9%, 59.3% and 51.7% of the patients showed low antibody titers that would be unlikely to protect against exposure to measles, rubella, hepatitis B and mumps, respectively. After receiving a vaccine booster dose for these antigens the patients had high antibody levels consistent with potential protection against measles, mumps and hepatitis B, but not against rubella.

Conclusion

Extra doses of measles-mumps-rubella plus hepatitis B vaccines are recommended in acute lymphoblastic leukemia patients submitted to treatment after hematologic recovery. After this, viral vaccine antibody levels should be verified to define the individual's protective status.