Live attenuated vaccines in patients receiving immunosuppressive agents

Post-varicella vaccination uveitis in a child with nephrotic syndrome receiving immunosuppressive treatment: a case report

Patients with nephrotic syndrome are at heightened risk of infections due to the underlying disease pathophysiology and the effects of immunosuppressive therapies. Varicella-zoster virus (VZV) infection can cause severe complications in immunocompromised individuals. Concerns about the safety of live attenuated vaccines in this population persist. Emerging vaccination strategies incorporate pre-vaccination risk stratification algorithms based on immunological criteria. We present a case of a five-year-old male with corticosteroid-dependent nephrotic syndrome, in complete remission on mycophenolate mofetil therapy, who received the varicella vaccine after meeting immunocompetence criteria. Fourteen days post-vaccination, he developed scant vesicular lesions, with VZV DNA detected by PCR via swab. By day 16 post-vaccination, he presented with left-eye panuveitis. VZV DNA was also detected in the blood by PCR. Differentiation of VZV vaccine strains from wild-type strains was not possible. Additionally, molecular testing for VZV in the aqueous humor was not performed. However, given the temporal association with varicella vaccination, the detection of VZV in the blood and cutaneous lesions, and most importantly, the immunosuppression of the patient, post-vaccination ocular varicella was assumed even without an epidemiological history of varicella exposure. This case highlights the importance of a thorough immunocompetence assessment before administering live vaccines to immunosuppressed patients, as well as close post-vaccine monitoring and a high index of suspicion for complications to optimize vaccine safety in this vulnerable group. Patients with nephrotic syndrome require vaccination strategies tailored to their individual risk.

Vaccines for preventing infections in adults with solid tumours

BACKGROUND

Infections are one of the most frequent complications seen in adults with cancer, often arising from the underlying condition or as a result of immunosuppressive treatments. Certain infections (e.g. influenza, pneumococcal disease, and meningococcal disease) may be prevented through vaccination. However, adults with solid tumours may elicit varying immune responses compared to healthy individuals.

OBJECTIVES

To assess the benefits and risks of vaccines for the prevention of infectious diseases in adults with solid tumours.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two further databases, and two study registries from inception to 2 December 2024 for randomised controlled trials (RCTs) and controlled non-randomised studies of interventions (NRSIs).

SELECTION CRITERIA

We included RCTs evaluating vaccines against the following infectious diseases in adults (≥ 18 years of age) with any diagnosis of solid tumour cancer compared to placebo or no vaccine: pneumococcal disease, Haemophilus influenzae type b disease, meningococcal disease, pertussis, hepatitis B, tetanus, polio, diphtheria, influenza, herpes zoster, and COVID-19. In cases where RCTs were unavailable, we included prospective controlled NRSIs. We excluded live-attenuated vaccines.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. Two review authors independently screened search results, extracted data, and assessed the risk of bias (RoB) in the included studies using the Cochrane RoB 2 tool for RCTs and ROBINS-I for NRSIs. We rated the certainty in the evidence using the GRADE approach for the following prioritised outcomes: incidence of infection concerned, all-cause mortality, quality of life, adverse events (AEs) of any grade, serious adverse events (SAEs), localised events at the injection site, and systemic events.

MAIN RESULTS

We included 10 studies (five RCTs and five NRSIs) involving 81,823 adults with solid tumours receiving vaccines to prevent infections with herpes zoster, influenza, or COVID-19. Six studies included participants with varied solid tumours, while two focused on neck and oesophageal cancer or lung cancer. We assessed the RCTs to be at low or moderate risk of bias, whereas most NRSIs were at critical risk of bias due to concerns about confounding. We identified two ongoing studies: one RCT evaluating an influenza vaccine, and one NRSI evaluating COVID-19 vaccines. Twelve studies are awaiting assessment. We did not identify RCTs or NRSIs of vaccines for preventing pneumococcal disease, Haemophilus influenzae type b disease, meningococcal disease, pertussis, hepatitis B, tetanus, polio, or diphtheria compared to placebo or no vaccine. The results from the RCTs are presented below. The results from the NRSIs are detailed in the main text of the review. No study reported quality of life. Vaccines for preventing herpes zoster compared to placebo or no vaccine Three RCTs (3054 participants) evaluated vaccines to prevent herpes zoster. Herpes zoster vaccines decrease the incidence of herpes zoster up to 29.4 months after the final dose (RR 0.37, 95% CI 0.23 to 0.59; 1 RCT, 2678 participants; high-certainty evidence). Herpes zoster vaccines probably make little or no difference to all-cause mortality up to 28 days after the final dose (RR 1.17, 95% CI 0.91 to 1.50; 2 RCTs, 2744 participants; moderate-certainty evidence); make little or no difference to any-grade AEs up to 30 days after final dose (RR 1.02, 95% CI 0.98 to 1.05; 3 RCTs, 2976 participants; high-certainty evidence), and probably make little or no difference in SAEs up to 30 days (RR 1.08, 95% CI 0.93 to 1.24; I² = 0%; 3 RCTs, 2976 participants; moderate-certainty evidence). Vaccines to prevent herpes zoster increase the number of participants with localised events at the injection site compared to placebo or no vaccine (RR 6.81, 95% CI 2.52 to 18.40; 3 RCTs, 2966 participants; high-certainty evidence) and may make little or no difference to the number of participants with systemic events up to 30 days after final dose (RR 1.08, 95% CI 0.77 to 1.50; 3 RCTs, 2966 participants; low-certainty evidence). Vaccines for preventing influenza compared to placebo or no vaccine One RCT (75 participants) evaluated vaccines to prevent influenza. We are uncertain about the effects of influenza vaccines administered prior to surgery on all-cause mortality (RR 1.00, 95% CI 0.07 to 15.33; 1 RCT, 66 participants; very low-certainty evidence), any-grade AEs (RR 1.17, 95% CI 0.89 to 1.54; 1 RCT, 75 participants; very low-certainty evidence), and SAEs (RR 1.46, 95% CI 0.76 to 2.83; 1 RCT, 75 participants; very low-certainty evidence) up to 15 days post-surgery. The RCT did not report the incidence of influenza, localised events at the injection site, or systemic events. Vaccines for preventing COVID-19 compared to placebo or no vaccine One RCT (2256 participants) evaluated vaccines to prevent COVID-19. Participants may have been exposed to the SARS-CoV-2 variants alpha, beta, and gamma. Vaccines to prevent COVID-19 probably decrease the incidence of COVID-19 in participants without previous COVID-19 infection up to six months after the second dose (RR 0.08, 95% CI 0.02 to 0.25; 1 RCT, 2100 participants; moderate-certainty evidence). The COVID-19 vaccines probably increase any-grade AEs (RR 1.99, 95% CI 1.71 to 2.30; 1 RCT, 2328 participants; moderate-certainty evidence). They may have little or no effect on SAEs up to 6 months after the second dose (RR 1.43, 95% CI 0.80 to 2.54; 1 RCT, 2328 participants; low-certainty evidence). The RCT did not report localised events at the injection site or systemic events.

AUTHORS' CONCLUSIONS

In adults with solid tumours, herpes zoster vaccines reduced the incidence of herpes zoster (high-certainty evidence), although localised events at the injection site were more likely to occur (high-certainty evidence). The evidence is very uncertain about the effects of influenza vaccines on all-cause mortality, any-grade AEs, and SAEs (very low-certainty evidence); the incidence of influenza was not measured in the studies. COVID-19 vaccines probably decrease the incidence of COVID-19 in those without prior infection (moderate-certainty evidence) but probably increase any-grade AEs (moderate-certainty evidence). We found no RCTs or NRSIs investigating vaccines for preventing pneumococcal disease, Haemophilus influenzae type b disease, meningococcal disease, pertussis, hepatitis B, tetanus, polio, diphtheria compared to placebo or no vaccine, in adults with solid tumours. Additional research, preferably of RCT design, is necessary to resolve uncertainties.

Recent Progress in Developing Extracellular Vesicles as Nanovehicles to Deliver Carbohydrate-Based Therapeutics and Vaccines

Cell-derived, nanoscale extracellular vesicles (EVs) have emerged as promising tools in diagnostic, therapeutic, and vaccine applications. Their unique properties including the capability to encapsulate diverse molecular cargo as well as the versatility in surface functionalization make them ideal candidates for safe and effective vehicles to deliver a range of biomolecules including gene editing cassettes, therapeutic proteins, glycans, and glycoconjugate vaccines. In this review, we discuss recent advances in the development of EVs derived from mammalian and bacterial cells for use in a delivery of carbohydrate-based protein therapeutics and vaccines. We highlight key innovations in EVs' molecular design, characterization, and deployment for treating diseases including Alzheimer's disease, infectious diseases, and cancers. We discuss challenges for their clinical translation and provide perspectives for future development of EVs within biopharmaceutical research and the clinical translation landscape.

Live-attenuated vaccines for multiple sclerosis patients living in regions with endemic infections: A complex decision

Live-attenuated vaccines provide robust immunity against diseases like tuberculosis, measles, mumps, rubella, polio, yellow fever, dengue, typhoid fever, and varicella, with just one or a few doses. However, concerns arise regarding potential pathogen reversion to virulence, which is particularly risky for immunocompromised individuals, contraindicating their administration in multiple sclerosis (MS) patients under modified disease treatments due to the possibility of triggering infections, or stimulating the immune system, precipitating new exacerbations. On the contrary, these vaccines offer enduring immunity that is crucial for protecting MS patients from endemic infectious diseases, leading to severe complications if contracted. These concerns underscore the complex balance between vaccination benefits and the risks of exacerbating MS in patients residing in regions with endemic diseases. This review explores the challenges and considerations associated with their use in MS patients, aiming to maximize benefits while minimizing risks.

Advancement in the development of mRNA-based vaccines for respiratory viruses

Acute respiratory infections are the leading cause of death and illness in children under 5 years old and represent a significant burden in older adults. Primarily caused by viruses infecting the lower respiratory tract, symptoms include cough, congestion, and low-grade fever, potentially leading to bronchiolitis and pneumonia. Messenger ribonucleic acid (mRNA)-based vaccines are biopharmaceutical formulations that employ mRNA molecules to induce specific immune responses, facilitating the expression of viral or bacterial antigens and promoting immunization against infectious diseases. Notably, this technology had significant relevance during the COVID-19 pandemic, as these formulations helped to limit SARS-CoV-2 virus infections, hospitalizations, and deaths. Importantly, mRNA vaccines promise to be implemented as new alternatives for fighting other respiratory viruses, such as influenza, human respiratory syncytial virus, and human metapneumovirus. This review article analyzes mRNA-based vaccines' main contributions, perspectives, challenges, and implications against respiratory viruses.

Vaccination of Adults With Cancer: ASCO Guideline

PURPOSE

To guide the vaccination of adults with solid tumors or hematologic malignancies.

METHODS

A systematic literature review identified systematic reviews, randomized controlled trials (RCTs), and nonrandomized studies on the efficacy and safety of vaccines used by adults with cancer or their household contacts. This review builds on a 2013 guideline by the Infectious Disease Society of America. PubMed and the Cochrane Library were searched from January 1, 2013, to February 16, 2023. ASCO convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

A total of 102 publications were included in the systematic review: 24 systematic reviews, 14 RCTs, and 64 nonrandomized studies. The largest body of evidence addressed COVID-19 vaccines.

RECOMMENDATIONS

The goal of vaccination is to limit the severity of infection and prevent infection where feasible. Optimizing vaccination status should be considered a key element in the care of patients with cancer. This approach includes the documentation of vaccination status at the time of the first patient visit; timely provision of recommended vaccines; and appropriate revaccination after hematopoietic stem-cell transplantation, chimeric antigen receptor T-cell therapy, or B-cell-depleting therapy. Active interaction and coordination among healthcare providers, including primary care practitioners, pharmacists, and nursing team members, are needed. Vaccination of household contacts will enhance protection for patients with cancer. Some vaccination and revaccination plans for patients with cancer may be affected by the underlying immune status and the anticancer therapy received. As a result, vaccine strategies may differ from the vaccine recommendations for the general healthy adult population vaccine.Additional information is available at www.asco.org/supportive-care-guidelines.

Live-attenuated vaccination for measles, mumps, and rubella in pediatric liver transplantation

BACKGROUND

Infections are a serious short- and long-term problem after pediatric organ transplantation. In immunocompromised patients, they can lead to transplant rejection or a severe course with a sometimes fatal outcome. Vaccination is an appropriate means of reducing morbidity and mortality caused by vaccine-preventable diseases. Unfortunately, due to the disease or its course, it is not always possible to establish adequate vaccine protection against live-attenuated viral vaccines (LAVVs) prior to transplantation. LAVVs such as measles, mumps, and rubella (MMR) are still contraindicated in solid organ transplant recipients receiving immunosuppressive therapy (IST), thus creating a dilemma.

AIM

This review discusses whether, when, and how live-attenuated MMR vaccines can be administered effectively and safely to pediatric liver transplant recipients based on the available data.

MATERIAL AND METHODS

We searched PubMed for literature on live-attenuated MMR vaccination in pediatric liver transplantation (LT).

RESULTS

Nine prospective observational studies and three retrospective case series were identified in which at least 833 doses of measles vaccine were administered to 716 liver transplant children receiving IST. In these selected patients, MMR vaccination was well tolerated and no serious adverse reactions to the vaccine were observed. In addition, an immune response to the vaccine was demonstrated in patients receiving IST.

CONCLUSION

Due to inadequate vaccine protection in this high-risk group, maximum efforts must be made to ensure full immunization. MMR vaccination could also be considered for unprotected patients after LT receiving IST following an individual risk assessment, as severe harm from live vaccines after liver transplantation has been reported only very rarely. To this end, it is important to establish standardized and simple criteria for the selection of suitable patients and the administration of the MMR vaccine to ensure safe use.

Herpes zoster in lupus nephritis: experience on 292 patients followed up for 15 years

Objectives

To evaluate the prevalence, incidence, and predictors of herpes zoster (HZ) development in lupus nephritis (LN).

Methods

This retrospective study included 292 LN patients to determine HZ incidence during the last decades and its correlation with LN activity. LN patients with HZ were matched with LN patients without HZ in a 1:2 ratio based on sex, age, year of LN diagnosis, and LN histological class at kidney biopsy to assess HZ risk factors. Statistical tests included t-test, U-test, and Fisher's test. Univariate and multivariate logistic regression analyses were conducted to identify potential risk factors.

Results

HZ occurred after LN diagnosis in 66 patients (prevalence 22.6%) with an average of 8.7 years (range 0.2-28.4 years). Although with the potential limitations of the retrospective nature and the extensive duration of the study, the incidence of HZ was 15.6/1,000 person-years, increasing from 6.9 before 1980 to 16.0 in the 1990s and 43.9 after 2010. HZ onset was unrelated to LN activity. LN was active in 43% of cases and quiescent in the other 57% of cases at HZ diagnosis. The percentage of patients who developed lupus flares during the year after HZ (18.9%) was not different from that which occurred during the year before HZ (17.2%, p = 0.804). After excluding confounding factors through matching, the univariate analysis suggested that cyclosporin during induction therapy (p = 0.011) and higher cumulative doses of glucocorticoids (GCs; >50 g, p = 0.004), cyclophosphamide (CYC; >5 g, p = 0.001), and mycophenolate mofetil (MMF > 1,000 g, p = 0.007) predisposed patients to HZ. Univariate and multivariate analyses revealed a protective role of azathioprine (p = 0.008) and methylprednisolone pulses (p = 0.010) during induction therapy.

Conclusions

HZ occurs unpredictably throughout the course of LN, underscoring the importance of continuous monitoring for these patients. In addition, the incidence of HZ seems to have increased in recent decades. Induction therapy with azathioprine and methylprednisolone pulses appears to provide protection, while higher cumulative doses of GCs, CYC, and MMF increase susceptibility.

Vaccination in the Era of Immunosuppression

Patients with autoimmune inflammatory rheumatic diseases (AIIRDs) are at increased risk for severe infections. Vaccine responses and safety profiles may differ between AIIRD patients and the general population. While patients with autoimmune inflammatory rheumatic diseases (AIIRDs) often experience diminished humoral responses and reduced vaccine efficacy, factors such as the type of immunosuppressant medications used and the specific vaccine employed contribute to these outcomes. Notably, individuals undergoing B cell depletion therapy tend to have poor vaccine immunogenicity. However, despite these considerations, vaccine responses are generally considered clinically sufficient. Ideally, immunosuppressed AIIRD patients should receive vaccinations at least two weeks before commencing immunosuppressive treatment. However, it is common for many patients to already be on immunosuppressants during the immunization process. Vaccination rarely triggers flares in AIIRDs; if flares occur, they are typically mild. Despite the heightened infection risk, including COVID-19, among AIIRD patients with rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, and other diseases on immunosuppressants, the vaccination rates remain suboptimal. The future directions of vaccination in the era of immunosuppression will likely involve customized vaccines with enhanced adjuvants and alternative delivery methods. By addressing the unique challenges faced by immunosuppressed individuals, we may improve vaccine efficacy, reduce the risk of infections, and ultimately enhance the health outcomes. Additionally, clinical trials to evaluate the safety and efficacy of temporarily discontinuing immunosuppressants during vaccination in various AIIRDs are crucial.