Guidelines on Vaccinations in Paediatric Haematology and Oncology Patients

Table 2

Summary of level of evidence and recommendations for paediatric patients during and after chemotherapy.

Vaccine	During chemotherapy		After chemotherapy
	Level of evidence, Reference	Concise recommendation	Level of evidence and reference	Concise recommendation
Poliomyelitis	C III; [21, 23]	Benefit of herd immunity; Postpone if lymphocyte count <1.0 × 10^9/L**	B II,; [10, 11, 57, 85, 87–89, 91]	Booster or vaccination 6 months after stopping chemotherapy
Diphteria	C III; [21, 24]	As above, passive immunoprophylaxis and antibiotic prophylaxis in case of epidemic	B II; [10, 11, 14, 26, 61, 86–91]	Booster or vaccination 6 months after stopping chemotherapy; (adult type vaccine for age >6 years)
Tetanus	C III; [21, 24]	Postpone if lymphocyte count <1.0 × 10^9/L**; Passive immunoprophylaxis, thorough washing and disinfection of wound, and antibiotic therapy for wounds at risk	B II; [11, 14, 26, 56, 61, 86, 87, 89, 91–93]	Booster or vaccination 6 months after stopping chemotherapy
Pertussis	C III; [21, 25]	Postpone if lymphocyte count <1.0 × 10^9/L**; Passive immunoprophylaxis and antibiotic prophylaxis in case of epidemic	B II; [10, 26, 86, 87, 90, 92]	Booster or vaccination 6 months after stopping chemotherapy
Hepatitis A virus	C III; [21, 27–30]	Vaccination of the seronegative patients before starting chemotherapy in highly endemic areas; alternatively, passive immuneprophylaxis	C III; [29]	Booster or vaccination 6 months after stopping chemotherapy
Hepatitis B virus*	B II; [21, 28, 31, 32, 34, 35]	As above	B II	Booster or vaccination 6 months after stopping chemotherapy
Influenza	B II; [21, 36–51, 53]	Vaccination yearly during fall; postpone if lymphocyte count <1.0 × 10^9/L;**; Vaccination of family members; Not administered to infants <6 months of age	B II; [14, 46, 49, 51, 52]	Fall Season vaccination after 3 months from stopping intensive chemotherapy; Not administered to infants <6 months of age
Meningococcus^§	C III; [21, 56, 57]	Recommended vaccination prior to splenectomy; Postpone vaccination if lymphocyte count <1.0 × 10^9/L**; Not administered if age <2 years	B II; [87]	Not administered if age <2 years; Booster or vaccination 6 months after stopping chemotherapy; Booster after 3 years if vaccinated at age of 2–6 years
Haemophilus influenzae	C III; [21, 24, 58, 61]	Not administered if age <2 months; Recommended vaccination prior to splenectomy; Postpone vaccination if lymphocyte count <1.0 × 10^9/L°°	B II; [11, 14, 87, 89]	Not administered if age <2 months; Booster or vaccination 6 months after stopping chemotherapy
Pneumococcus^§,§§	C II; [20, 41, 55–58]	Recommended vaccination prior to splenectomy; Postpone vaccination if lymphocyte count <1.0 × 10^9/L**	B II; [87]	Booster or vaccination 6 months after stopping chemotherapy
Measles, Mumps,; Rubella	D III; [21, 64]	Not administered if age <12 months; Passive immunoprophylaxis in case of contact; Vaccination of seronegative family members	B II [11, 12, 56, 61, 86, 87, 89, 92]	Not administered if age <12 months; Booster or vaccination 6 months after stopping chemotherapy
Measles	CIII; (if epidemics); [64]	In case of epidemic, patient vaccination if adequate CD4+ immune recovery°
Varicella	C II; [21, 63, 67, 69–73]	Postpone if lymphocyte count <0.7–1.2 × 10^9/L** or the patient is not in remission for 12 months or is doing radiotherapy; Not administered if age <12 months; Vaccination of family members at risk; Postexposure prophylaxis within 96 hours from contact: hyperimmune Ig (0.2 mL/kg, max 10 mL); 96 hours after contact; Acyclovir 4 × 20 mg/kg/day from the 7th to 21st days**	B II; [11, 57, 65, 89]	Not administered if age <12 months; Booster or vaccination 6 months after stopping chemotherapy
Human papilloma virus	No data		C III; [22]	Not administered if age <9 years; Booster or vaccination 6 months after stopping chemotherapy
Rotavirus	No data		No data

Legend:
 *Observe a 4-week interval between 1st and 2nd doses and 3-month interval between the 3rd and 4th doses of vaccine for hepatitis B virus.
§Meningococcal and pneumococcal polysaccharide vaccines are not effective in children <2 years.
§§Minimum age for conjugated vaccine is 6 weeks of age. Use pneumococcal conjugate vaccine followed, after at least 2 months, by the 23 polysaccharide vaccine. In case of splenectomy, give a booster after surgery.
°Threshold level of CD4+ recovery for MMR vaccination: CD4+ > 0.75 × 10⁹/L for children <12 months; CD4+ > 0.5 × 10⁹/L for children aged 1–5 years; >0.2 × 10⁹/L for children >6 years old and adults.
**As suggested by [72, 73].
°°Expert panel opinion. The use of acyclovir as postexposure prophylaxis has been successfully reported in immunocompetent host contacts with VZV.