The Controversy of Varicella Vaccination in Children With Acute Lymphoblastic Leukemia

Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee 38105-2794, USA.
Pediatric Blood & Cancer (Impact Factor: 2.39). 01/2012; 58(1):12-6. DOI: 10.1002/pbc.22759
Source: PubMed


The available guidelines for varicella vaccination of susceptible children with acute lymphoblastic leukemia (ALL) have become increasingly conservative. However, vaccination of those who have remained in continuous complete remission for 1 year and are receiving chemotherapy is still considered a reasonable option. There is little available data to allow a comparison of the risk versus benefit of vaccinating these patients.
We retrospectively reviewed mortality due to varicella in the records of 15 pediatric ALL study groups throughout Europe, Asia, and North America during the period 1984-2008.
We found that 20 of 35,128 children with ALL (0.057%; 95% confidence interval [CI], 0.037-0.088%) died of VZV infection. The mortality rate was lower in North America (3 of 11,558 children, 0.026%; 95% CI, 0.009-0.076%) than in the Asian countries (2 of 4,882 children, 0.041%; 95% CI, 0.011-0.149%) and in Europe (15 of 18,688 children, 0.080%; 95% CI, 0.049-0.132%) consistent with the generally higher rate of VZV vaccination in North America. Fourteen of the 20 patients (70%) died during the first year of treatment for ALL. One death was attributed to varicella vaccination.
The negligible rate of fatal varicella infection in children with ALL, the risk that accompanies vaccination, and the necessity of withholding chemotherapy for vaccination appear to outweigh the potential benefit of varicella vaccination for children during treatment of ALL.

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Available from: Giuseppe Masera, May 13, 2014
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    • "The risk of mortality of varicella significantly decreased over the last 20 years with the introduction of acyclovir and, more recently, of other effective agents such as foscarnet and cidofovir [76, 77]. Taken altogether, the potential side effects must be weighed against the real benefits in any decision to vaccinate for HVZ seronegative leukemic patients while they are on therapy [76–78]. "
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    ABSTRACT: 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.
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    • "found that chemotherapy is associated with the disappearance of vaccination immunity in patients who had completed the vaccination schedule before starting chemotherapy[82– 93]. The incidence of lack of protective antibody titres measured 6–12 months after chemotherapy varied according the type of vaccine: it was higher for HBV (about 50% of patients) whilst it was lower for measles, mumps, rubella (between 20% and 40%), and polio-diphtheria-tetanus (between 10% and 30%)[12,25,65,76,8283848586. Although there is no clear correlation between the wide variation in the preservation of vaccine immunity and the type of cancer, i.e., lymphoid versus myeloid versus solid tumour, the intensity of chemotherapy regimen has been advocated by Ek et al. to explain the insufficient immune response to tetanus, diphtheria, and Haemophilus influenzae b vaccination after chemotherapy for high-risk acute lymphoblastic leukaemia, because of a delayed immune recovery and a low number of memory B cells[14,94]. "
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    ABSTRACT: Aim - Defining the guidelines on vaccinations in paediatric cancer patients. Method - We reviewed the literature published from 1980 to 2009 according to the methodology suggested by the American Society of Infectious Disease. The intention was to define recommendations on vaccinations in patients both during and after chemotherapy as well as recommendation on vaccinations in family members. The conclusions achieved were presented in 2 plenary discussion sessions before final approval. In case of disagreement the issue was settled by discussion with an external expert. Results - While on chemotherapy, the patient benefits HBV and influenza vaccinations. During this phase, family members are advised to continue vaccinations as scheduled by health plan or, if seronegative, vaccinations against varicella, measles, mumps, rubeola are recommended. Although a reduction of serum antibody levels for vaccine-preventable disease is reported following suspension of chemotherapy, the immunological memory seems preserved. The response to booster is generally good, gives the patients good protection and contributes to herd immunity.
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