Assessment of serologic immunity to diphtheria-tetanus-pertussis after treatment of Korean pediatric hematology and oncology patients

Vaccine Immunity in Children After Hematologic Cancer Treatment: A Retrospective Single-center Study

BACKGROUND

Children lose their vaccine-induced protection and are particularly vulnerable to vaccine-preventable diseases after chemotherapy. However, revaccination guidelines are heterogeneous, and there is often a lack of revaccination post-treatment.

AIMS

We conducted a retrospective study of children with hematologic cancer to evaluate vaccine immunity before and after the end of treatment and to determine whether the current institutional revaccination program based on vaccine serology results was followed and effective.

MATERIALS AND METHODS

Data of all children treated by chemotherapy between April 2015 and July 2021 were extracted from hospital medical records for analysis. Serum antibody levels and time of vaccination were evaluated for diphtheria, tetanus, Streptococcus pneumoniae , Haemophilus influenzae type b (Hib), measles, varicella, and hepatitis B.

RESULTS

We included 31 patients (median age, 9 years). At cancer diagnosis, 90% of children were protected against tetanus, diphtheria, and measles; 65% to 67% were protected against pneumococcus and varicella; and 25% against hepatitis B. At the end of chemotherapy, 67% to 71% of patients were protected against tetanus, varicella, and measles; 40% remained protected against hepatitis B; and 27% to 33% against pneumococcus and diphtheria. Patients were revaccinated at various times after the end of treatment but not systematically. During the first-year post-treatment, 20% to 25% of children remained unprotected against pneumococcus, measles, and hepatitis B, one third against diphtheria, but all were protected against tetanus and varicella.

CONCLUSIONS

An effective individualized vaccination program post-cancer based on serology results should be accompanied by an appropriate serology tracking method and follow-up to assess if booster doses are necessary. Our study supports vaccinating all children with a dose of the 13-valent pneumococcal conjugate at cancer diagnosis and at 3 months post-treatment with the combined diphtheria-tetanus-acellular pertussis/poliomyelitis vaccine/hepatitis B virus plus or minus Hib and 13-valent pneumococcal conjugate and meningococcal vaccine, including measles/mumps/rubella-varicella zoster virus vaccine if good immune reconstitution is present.

Cutaneous diphtheria complicated oncologic reconstruction surgery in osteosarcoma

Diphtheria is an uncommon bacterial infection of the upper respiratory tract. We described a surgical site infection in a young adolescent female on maintenance chemotherapy. Corynebacterium diphtheriae was recovered from the wound, and she was treated with antibiotics and antitoxin. Cutaneous diphtheria should be considered in immunocompromised patients receiving chemotherapy.

Patterns and correlates of preserved humoral immunity to vaccines in children following allogeneic hematopoietic stem cell transplantation

Data on preservation of vaccine immunity following allogeneic HSCT in children is limited. We investigated vaccine titers and sought correlations with patient characteristics in this study. Twenty-eight cases were retrospectively analyzed. Antibody concentrations against hepatitis A, hepatitis B, 3 poliovirus serotypes, tetanus, diphtheria, measles, mumps, rubella, varicella, and 13 pneumococcus serotypes were measured as part of planned monitoring following HSCT. Protective antibody levels were found for hepatitis A in 79% of the recipients, measles in 54%, all poliovirus serotypes in 50%, tetanus in 50%, rubella in 50%, varicella in 46%, hepatitis B in 46%, mumps in 43%, diphtheria in 29%, and ≥7/13 pneumococcus serotypes in 46%; lowest level observed for diphtheria and highest for hepatitis A prior to starting post-HSCT immunizations. In univariate analysis, patients with non-malignant diseases (P = .03) and without GvHD (P = .04) had more protective titers. A significant positive association was found among vaccine titers against the microorganisms or the serotypes of the same microorganism, which were administered together in the same product, including polio serotypes, diphtheria and tetanus, mumps, measles, and rubella. Higher degrees of sero-positivity are likely to be due to lack of prior chemotherapy in non-malignant disease cases and lesser immunosuppression in patients without GvHD. Monitoring long-term vaccine titers and administering vaccines accordingly could be evaluated for post-HSCT re-immunization practice.

Vaccination Against Diphtheria and Tetanus as a Way to Activate Adaptive Immunity in Children with Solid Tumors

Early studies on vaccination of children with oncological diseases were only dedicated to the assessment of safety and immunogenicity of the drug. Mechanisms of the post-vaccination immune response were not investigated. This study involved 41 patients aged 7-15 years who were treated for solid tumors two or more years ago. Of these, 26 were vaccinated against diphtheria and tetanus with ADS-m toxoid. Fifteen children (i.e., controls) were not vaccinated. The vaccination tolerability and clinical characteristics of the underlying disease remission ware assessed. Lymphocyte subpopulations were investigated over time by flow cytometry at 1, 6, and 12 months. IgG anti-diphtheria and anti-tetanus toxoids levels were assessed by ELISA. Within the first day of the post-vaccination period, two (7.7%) children demonstrated moderate local reactions and increased body temperature (up to 38.0°C). Relapse and metastasis were not mentioned within a year after immunization. An increase in concentration of IgG antibodies, maintained for 12 months, were noted [2.1 (1.3-3.4) IU/ml against diphtheria (p <0.001), 6.4 (2.3-9.7) IU/ml against tetanus (p <0.001)]. In contrast to healthy children, those with a history of cancer demonstrated a decrease in the relative number of mature T lymphocytes, as well as in absolute number of cytotoxic T cells and B lymphocytes. In a month after the revaccination, a significant increase in absolute (p = 0.04) and relative (p = 0.007) numbers of T lymphocytes and T helpers was revealed. In a year, these values decreased to baseline levels. As for helpers, they decreased below baseline and control values (p = 0.004). In a year after the vaccination, there was a significant (p = 0.05) increase in lymphocyte level with a decrease in the number of NK cells and B cells as compared with controls. Revaccination against diphtheria and tetanus promoted proliferation of a total lymphocytic cell pool along with restoration of the T lymphocyte subpopulation in children with a history of solid tumors. The ADS-m toxoid has a certain nonspecific immunomodulatory effect. These findings are important, also in the midst of the coronavirus pandemic.

Waning Vaccine Immunity and Vaccination Responses in Children Treated for Acute Lymphoblastic Leukemia: A Canadian Immunization Research Network Study

BACKGROUND

There is no uniform guideline for postchemotherapy vaccination of children with acute lymphoblastic leukemia (ALL). We evaluated waning immunity to 14 pneumococcal serotypes, pertussis toxin (PT), tetanus toxoid (TT) and varicella, and immunogenicity of postchemotherapy diphtheria, tetanus, pertussis, hepatitis B, polio, and Haemophilus influenzae type b (DTaP-IPV-Hib) and pneumococcal vaccination among previously vaccinated children treated for ALL.

METHODS

This was a multicenter trial of children with ALL enrolled 4-12 months postchemotherapy completion. Exclusion criteria included: infant ALL, relapsed ALL, and stem cell transplant recipients. Immunocompetent children were recruited as controls. Postchemotherapy participants received DTaP-IPV-Hib and 13-valent pneumococcal conjugate vaccine (PCV13) concurrently, followed by 23-valent pneumococcal polysaccharide vaccine (PPV23) 2 months later. Serology was measured at baseline, 2 and 12 months postvaccination. Adverse events were captured via surveys.

RESULTS

At enrollment, postchemotherapy participants (n = 74) were less likely than controls (n = 78) to be age-appropriately immunized with DTaP (41% vs 89%, P < .001) and PCV (59% vs 79%, P = .008). Geometric mean concentrations (GMCs) to TT, PT, PCV serotypes, and varicella were lower in postchemotherapy participants than controls after adjusting for previous vaccine doses (P < .001). Two months postvaccination, GMCs to TT, PT, and PCV serotypes increased from baseline (P < .001 for all antigens) and remained elevated at 12 months postvaccination. Antibody levels to PPV23 serotypes also increased postvaccination (P < .001). No serious adverse events were reported.

CONCLUSIONS

Children treated for ALL had lower antibody levels than controls against pneumococcal serotypes, tetanus, pertussis, and varicella despite previous vaccination. Postchemotherapy vaccination with DTaP-IPV-Hib, PCV13, and PPV23 was immunogenic and well tolerated. Children with ALL would benefit from systematic revaccination postchemotherapy.

CLINICAL TRIALS REGISTRATION

NCT02447718.

Evaluation of INSTAND e.V.'s external proficiency testing program for tetanus and diphtheria antitoxin detection: Lessons for assessing levels of immunoprotection

OBJECTIVES

The aim of this study was to evaluate the development and status quo of the quality of high throughput in vitro diagnostic testing for tetanus and diphtheria antitoxin antibody (ATX) concentrations based on external quality assessment (EQA) data.

METHODS

We analyzed manufacturer-specific data of 22 EQA surveys-each for the detection of tetanus and diphtheria ATX-to check the diagnostic strength of the corresponding in vitro diagnostic systems.

RESULTS

While the results were mostly well aligned, individual surveys showed widely dispersed ATX concentrations. The medians of manufacturer collectives deviated from the overall median by up to 8.9-fold in the case of diphtheria ATX and by up to 3.5-fold in the case of tetanus ATX. Such a distribution in the results is particularly critical in the cut-off range for immunity and may lead to an incorrect assessment of vaccination status.

CONCLUSION

These results were surprising as there are International Standards for both ATX; however, the results may be linked to the high ATX concentration of the reference material, which deviates considerably from clinically significant concentrations. To increase the accuracy and diagnostic strength of both assays, we recommend a recalibration of the test systems and verification of their traceability to the International Standards.

The Impact of Chemotherapy after Pediatric Malignancy on Humoral Immunity to Vaccine-Preventable Diseases

Background/Aim

The antibody titer of vaccine-preventable diseases in pediatric patients who underwent chemotherapy was assessed in order to evaluate the seroprotection after treatment and the feasibility and the efficacy of a policy of revaccination.

Methods

Serum antibody titers of 55 patients for hepatitis B (HBV), rubella, varicella-zoster (VZV), measles, mumps, polio viruses, Clostridium tetani (C. tetani) and Streptococcus pneumoniae (S. pneumoniae) were analysed.

Results: After chemotherapy, a lack of protective antibody titers against HBV, rubella, VZV, measles, mumps, polio viruses, C. tetani, and S. pneumoniae was found in 53%, 45%, 46%, 46%, 43%, 21–26%, 88% and 55% of patients, respectively. In 49 of 55 patients who were tested both before and after chemotherapy for at least a pathogen, the loss of immunity for HBV, rubella, VZV, measles, mumps, polio viruses and C. tetani was respectively 39%, 43%, 38%, 42%, 32%, 33%, and 80%. A low number of B-lymphocytes was associated with the loss of immunity against measles (p=0.04) whereas a high number of CD8+ T-lymphocytes was associated with the loss of immunity against VZV (p=0.03). A single booster of vaccine dose resulted in a seroprotection for HBV, rubella, VZV, measles, mumps, polio viruses, C. tetani and S. pneumoniae in 67%, 83%, 80%, 67%, 33%, 100%, 88% and 67% of patients, respectively.

Conclusions

We confirm that seroprotection for vaccine-preventable diseases is affected by treatment for pediatric malignancy. A single booster dose of vaccine might be a practical way to restore vaccine immunity in patients after chemotherapy.

Survivorship, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Survivorship provide screening, evaluation, and treatment recommendations for common physical and psychosocial consequences of cancer and cancer treatment to help healthcare professionals who work with survivors of adult-onset cancer in the posttreatment period. This portion of the guidelines describes recommendations regarding the management of anthracycline-induced cardiotoxicity and lymphedema. In addition, recommendations regarding immunizations and the prevention of infections in cancer survivors are included.

Vaccination of patients with haematological malignancies who did not have transplantations: guidelines from the 2017 European Conference on Infections in Leukaemia (ECIL 7)

Patients with haematological malignancies are at high risk of infection because of various mechanisms of humoral and cell-mediated immune deficiencies, which mainly depend on underlying disease and specific therapies. Some of these infections are vaccine preventable. However, these malignancies are different from each other, and the treatment approaches are diverse and rapidly evolving, so it is difficult to have a common programme for vaccination in a haematology ward. Additionally, because of insufficient training about the topic, vaccination is an area often neglected by haematologists, and influenced by cultural differences, even among health-care workers, in compliance to vaccines. Several issues are encountered when addressing vaccination in haematology: the small size of the cohorts that makes it difficult to show the clinical benefits of vaccination, the subsequent need to rely on biological parameters, their clinical pertinence not being established in immunocompromised patients, scarcity of clarity on the optimal timing of vaccination in complex treatment schedules, and the scarcity of data on long-term protection in patients receiving treatments. Moreover, the risk of vaccine-induced disease with live-attenuated vaccines strongly limits their use. Here we summarise guidelines for patients without transplantations, and address the issue by the haematological group-myeloid and lymphoid-of diseases, with a special consideration for children with acute leukaemia.

Immunity to tetanus in major beta thalassemia patients

Purpose

Patients with beta thalassemia major are at increased risk for bacterial infections specially splenectomized patients. The aim of this study was to determine the anti-tetanus antibody concentration among patients with beta thalassemia major.

Materials and Methods

The anti-tetanus antibody concentration was investigated in 224 patients with thalassemia major and 224 healthy subjects matched for age and gender. Tetanus antibody and ferritin serum level were determined by enzyme-linked immunosorbent assay method using commercial kits. Subjects who had antibody level ≥ 0.1 IU/mL was defined as complete protection, 0.01 to < 0.1 IU/mL as partial protection and < 0.01 IU/mL as no protection. For the analysis, we used SPSS version 11.5 software. A two-sided p-value less 0.05 was considered statistically significant.

Results

In patients with beta thalassemia major, antibody level against tetanus was inversely dependent about 29.3% to serum ferritin level. Thus, when serum ferritin increased 1 ng/mL, serum antibody against tetanus decreased 0.002 IU/mL. Mean anti-tetanus (IgG) antibody titers was lower in thalassemia patients compared to healthy subjects (1.53 ± 1.71 vs. 2.02 ± 2.05, p = 0.007) that was no significantly associated to age and gender in both study groups. All of participants had serum antibody level 0.01 IU/mL or greater. The complete protective level of anti-tetanus antibody was lower in thalassemia subjects in compare to healthy persons (71% vs. 87.9%, p < 0.001).

Conclusion

Patients with thalassemia had lower anti-tetanus antibody level than healthy subjects. Thus the vaccine recommendation seems essential for patients with beta thalassemia major.

Knowledge and Acceptability about Adult Pertussis Immunization in Korean Women of Childbearing Age

PURPOSE

The adult tetanus, reduced diphtheria, and acellular pertussis (Tdap) vaccine has been introduced in order to provide individual protection and reduce the risk of transmitting pertussis to infants. We assessed the knowledge and acceptability of the Tdap vaccine around pregnancy.

MATERIALS AND METHODS

This study was a cross-sectional survey of women of childbearing age (20-45 years) who visited obstetrics and gynecologic units of primary, secondary, or tertiary hospitals. They were asked to fill in a questionnaire assessing their knowledge, attitudes, and acceptability of Tdap.

RESULTS

The questionnaire was completed by 308 women; 293 (95.1%) had not received information from doctors about Tdap, and 250 (81.2%) did not know about the need for vaccination. A significantly important factor related to subjects' intention to be vaccinated, identified by stepwise multiple logistic regression, was the knowledge (OR 13.5, CI 3.92-46.33) that adult Tdap is effective in preventing pertussis for infants aged 0-6 months. Additionally, 276 (89.6%) considered the recommendation of obstetric doctors as the most influencing factor about Tdap vaccination.

CONCLUSION

In Korea, most women of childbearing age seem to be neither recommended nor adequately informed about the vaccination, although our population was not a nationwide representative sample. Information given by healthcare workers may be critical for improving awareness and preventing pertussis.

Practical review of immunizations in adult patients with cancer

Compared with the general population, patients with cancer in general are more susceptible to vaccine-preventable infections, either by an increased risk due to the malignancy itself or immunosuppressive treatment. The goal of immunizations in these patients is therefore to provide protection against these infections, and to decrease the number of vulnerable patients who can disseminate these organisms. The proper timing of immunization with cancer treatment is key to achieving better vaccine protection. As the oncology field continues to advance, leading to better quality of life and longer survival, immunization and other aspects of preventive medicine ought to move to the frontline in the care of these patients. Herein, we review the vaccines most clinically relevant to patients with cancer, as well as special cases including vaccines after splenectomy, travel immunization and recommendations for family members.

Guidelines on vaccinations in paediatric haematology and oncology patients

OBJECTIVE

Vaccinations are the most important tool to prevent infectious diseases. Chemotherapy-induced immune depression may impact the efficacy of vaccinations in children.

PATIENTS AND METHODS

A panel of experts of the supportive care working group of the Italian Association Paediatric Haematology Oncology (AIEOP) addressed this issue by guidelines on vaccinations in paediatric cancer patients. The literature published between 1980 and 2013 was reviewed.

RESULTS AND CONCLUSION

During intensive chemotherapy, vaccination turned out to be effective for hepatitis A and B, whilst vaccinations with toxoid, protein subunits, or bacterial antigens should be postponed to the less intensive phases, to achieve an adequate immune response. Apart from varicella, the administration of live-attenuated-virus vaccines is not recommended during this phase. Family members should remain on recommended vaccination schedules, including toxoid, inactivated vaccine (also poliomyelitis), and live-attenuated vaccines (varicella, measles, mumps, and rubella). By the time of completion of chemotherapy, insufficient serum antibody levels for vaccine-preventable diseases have been reported, while immunological memory appears to be preserved. Once immunological recovery is completed, usually after 6 months, response to booster or vaccination is generally good and allows patients to be protected and also to contribute to herd immunity.

Immunization of children receiving immunosuppressive therapy for cancer or hematopoietic stem cell transplantation

In the past 3 decades, the number of immunocompromised children has increased steadily because of dramatic improvement in survival rates in certain malignancies as a result of intensive curative treatment regimens and an increase in the number of children undergoing life-saving hematopoietic stem cell transplantation (HSCT). Children receiving immunosuppressive therapy for cancer, as well as HSCT recipients, will benefit from vaccination but warrant close evaluation for a variety of reasons, such as the risk of developing severe infections, serious adverse events following certain vaccines, and decreased vaccine efficacy caused by poor immune response to vaccination. Various professional organizations have published vaccination guidelines for immunocompromised patients. Given their heterogeneity, recommendations for the immunization of immunocompromised patients may not be universally applicable. The safety of many commonly used vaccines has not been established in immunocompromised children. In addition, no large-scale vaccine studies have evaluated the clinical outcome of disease prevention in this population. All killed vaccines are generally safe, while live vaccines may be administered to immunocompromised children in select circumstances, depending on the degree of altered immunocompetence and the underlying primary condition. Healthcare providers should be knowledgeable about the indications, contraindications, and precautions for vaccine administration in immunocompromised patients. To protect immunocompromised patients, all family, household contacts, and healthcare workers should also be immunized with all routinely recommended vaccines. Pediatricians play a crucial role in identifying and effectively communicating the risks and benefits of vaccines to immunocompromised patients and their parents.