Vaccination for herpes zoster in patients with solid tumors: a position paper on the behalf of the Associazione Italiana di Oncologia Medica (AIOM)

Prevention of herpes zoster in acquired immunocompromised conditions: Review of updates and perspectives from Hong Kong

Patients with acquired immunocompromising conditions face considerable risk of developing herpes zoster (HZ). Based on the underlying medical conditions and degree of immune dysfunction, these patients require tailored strategies for HZ prevention. In Hong Kong, there is currently a lack of guidelines addressing the unique needs of this vulnerable population, including the use of prophylactic measures such as antivirals and vaccines. An expert panel comprising clinical immunologists, nephrologists, infectious diseases specialists, rheumatologists, hematologists and oncologists in Hong Kong met to review current literature and international guidelines to propose a locally adapted decision-making framework for HZ prophylaxis, in patients with acquired immunocompromised conditions. This article summarizes the consensus and presents a guiding criteria for clinicians to navigate the complexities associated with HZ prevention, in the context of acquired immunodeficiency.

Vaccination of people with solid tumors and diabetes: existing evidence and recommendations. A position statement from a multidisciplinary panel of scientific societies

Diabetes and cancer are two of the most common public health concerns worldwide. The complex interplay of these two conditions is a growing area of research, as patients with diabetes are at increased risk for developing cancer, and vice versa. Furthermore, both patient populations show increased risk of many communicable infectious diseases and their adverse consequences, while vaccination can play a crucial role in their prevention, improving patient outcomes. Vaccination should represent a standard part of care for patients with cancer, diabetes, and both the diseases simultaneously, including people undergoing cancer treatment or in remission. Several international guidelines provide recommendations for vaccinating people with cancer or diabetes, but the two conditions have not been specifically evaluated together. Here we present a multidisciplinary consensus position paper on vaccination in patients with cancer and diabetes. The position paper is the result of a collaborative effort between experts from the Italian Association of Medical Oncology (AIOM), Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Italian Society of Endocrinology (SIE), and Italian Society of Pharmacology (SIF). The paper provides a comprehensive overview of the current state-of-the-art knowledge on vaccination in patients with cancer and diabetes. It discusses the importance of vaccination in preventing infections, focuses attention on the need to consider the unique challenges faced by patients with cancer and diabetes when it comes to vaccine administration, and highlights the need for coordinated care to optimize treatment outcomes. Overall, the consensus position paper provides healthcare professionals caring for patients with cancer and diabetes recommendations on the use of various vaccines, including influenza, COVID-19, HZV, and HPV vaccines, as well as guidance on how to address common concerns and challenges related to vaccine administration.

How Should We Manage the Impact of Antimicrobial Resistance in Patients With Cancer? An Oncological and Infectious Disease Specialist Point of View

Patients with solid tumors present a higher risk of infectious diseases with worse outcomes compared with immunocompetent patients. Prolonged treatment of prophylactic and empirically chosen antibiotics and health care-acquired infections can predispose patients with cancer to infections with antimicrobial-resistant (AMR) organisms. AMR is a global health priority and can affect patients with cancer. The outcome of patients with cancer worsens dramatically if multidrug-resistant (MDR) microorganisms cause infections. Moreover, the emergence of MDR organisms increases health care costs. Antimicrobial stewardship programs can be useful to monitor and improve the use of antibiotics in all oncological settings, including the palliative setting. Awareness of the magnitude of these issues is still low, so it is important to inform and educate oncologists. This narrative review aims to illustrate the main evidence on infections caused by AMR organisms in patients with cancer and the tools that oncologists should have to enhance their multidisciplinary management.

Vaccine hesitancy in patients with solid tumors: a cross-sectional single-center survey

BACKGROUND

Vaccination rates are still suboptimal in cancer patients. Oncologists play a central role in recommending vaccines to their patients. Our goal was to investigate vaccine acceptance among cancer patients and understand the factors shaping their choices, thereby aiding physicians in better supporting their patients' vaccination decisions.

METHODS

We designed a prospective cross-sectional survey exploring vaccination status, attitudes, and reasons for hesitancy towards vaccinations against the main vaccine preventable diseases (VPDs) among patients undergoing active cancer treatment. The primary endpoint was to evaluate the proportion of vaccinated subjects in our cohort of cancer patients. The secondary endpoints were to assess the proportion of vaccinated subjects against different types of VPDs: flu, COVID-19, pneumococcal disease, Herpes Zoster (HZ).

RESULTS

Between 12 February and 01 March 2024, a total of three hundred and seventeen patients with cancer were invited to respond to the survey, 309 of whom (97%) agreed to do it. Two hundred seventy-three patients (0.88, 95% confidence interval [CI] 0.84-0.91) had received at least one vaccination. Two hundred thirty-one patients (74.76%) reported that at their first oncology visit their oncologist recommended vaccinations, primarily anti-flu (92.21%) and anti-SARS-CoV-2 (83.55%) vaccinations, while less frequently the anti-pneumococcal (42.42%) and anti-HZ (37%) vaccines were recommended. On the univariate analysis, age over 75 years (p = 0.041), marital status (p = 0.003) and the oncologist's vaccine recommendation during the first visit (p < 0.001) were significantly associated to vaccine acceptance. At the multivariable analysis, these variables were independently associated with vaccine willingness. Overall in our cancer population, the two main reasons for vaccine hesitancy were the lack of recommendation by the oncologist (55.41%, n = 128) and the lack of awareness of the importance of vaccination in the context of oncological care (49.35%, n = 114).

CONCLUSIONS

This survey emphasizes the importance of vaccine counseling by the oncologist to their patients. Oncologists can motivate patients to receive the correct vaccine schedule by addressing doubts and concerns about the potential negative impact of the vaccine on cancer and cancer therapies.

Evaluation of the common skin diseases in patients with malignancies and the cutaneous side effects of cancer treatments

PURPOSE

The diversity of skin diseases in patients with malignancies leads to diagnostic difficulties and complicate cancer treatment. Furthermore, the increasing use of chemotherapy drugs and novel treatment regimens raises the risk of the development of various cutaneous side effects and the need for dermatologists during cancer management. We investigated the skin diseases in patients with malignancies and the cutaneous side effects of cancer treatments.

METHODS

Medical records of cancer patients evaluated in the Dermatology clinic between July 2018 and April 2023 were retrospectively reviewed.

RESULTS

This study included 872 cancer patients, 374 females and 498 males. Acute myeloid leukaemia was the most common malignancy, followed by multiple myeloma and invasive ductal breast carcinoma. Graft versus host disease was observed in 89 (10.2%) patients after stem cell transplantation and radiodermatitis developed in 16 (1.8%) patients. Maculopapular drug eruption and hand foot syndrome were the most common cutaneous side effects of chemotherapy drugs. Capecitabine was the most common etiologic agent in hand foot syndrome. Cellulitis was the most frequent bacterial infection in cancer patients, whereas herpes zoster was the most frequent viral infection. Among the chemotherapy drugs that caused acneiform drug eruption, cetuximab and cytarabine were notable. Facial erythema was associated with cytarabine use in 27.3% of patients.

CONCLUSION

Identifying the common skin diseases in cancer patients and cutaneous side effects due to chemotherapy drugs may help to take preventive measures, develop specific and effective treatments, determine the most appropriate cancer treatment options, and increase patients' compliance with cancer treatment.

A Survey on Knowledge and Attitudes Towards Vaccination Against Herpes Zoster Virus Among Medical Oncologists for Patients with Solid Tumors

Herpes zoster (HZ) virus reactivation is a significant medical problem among immunocompromised patients, especially considering its potential complications. Although the recombinant HZ vaccine has demonstrated > 90% efficacy against HZ in adults, its use is not as frequent as needed in daily oncology practice due to several barriers, including oncologists' knowledge, patients' willingness, and organizational issues. A web-based survey was sent to 139 oncologists treating solid tumors concerning their knowledge and attitudes toward the adjuvanted gE-based recombinant HZ vaccination. The survey included questions regarding the characteristics of medical oncologists participating, such as the type of hospital, main field of expertise, percent of work with patients, awareness of the HZ risk in cancer patients, knowledge of scientific data and scientific societies guidelines on HZ vaccination, familiarity with vaccinations, frequency of HZ detection in clinical practice, barriers, and challenges toward vaccine administration. Fifty-four physicians (46%; 95% CI 0.2918 to 0.5069) responded to all the questions. The main reason for non-response was the lack of time due to the overwhelming burden of assistance. When the survey was launched, 31 participants reported good knowledge of scientific and clinical data of HZ vaccines, 10% none, and 36 were aware of guidelines. Reported barriers included knowledge of the problem, patients' willingness, and organizational issues. Surveying medical oncologists on the adjuvanted gE-based recombinant HZ vaccination provides essential insights into their knowledge, attitudes, and practices regarding vaccination for cancer patients. These data suggest that continuing medical education is necessary to implement HZ vaccination prescription among oncologists.

Mannan-Decorated Lipid Calcium Phosphate Nanoparticle Vaccine Increased the Antitumor Immune Response by Modulating the Tumor Microenvironment

With the rapid development of tumor immunotherapy, nanoparticle vaccines have attracted much attention as potential therapeutic strategies. A systematic review and analysis must be carried out to investigate the effect of mannose modification on the immune response to nanoparticles in regulating the tumor microenvironment, as well as to explore its potential clinical application in tumor therapy. Despite the potential advantages of nanoparticle vaccines in immunotherapy, achieving an effective immune response in the tumor microenvironment remains a challenge. Tumor immune escape and the overexpression of immunosuppressive factors limit its clinical application. Therefore, our review explored how to intervene in the immunosuppressive mechanism in the tumor microenvironment through the use of mannan-decorated lipid calcium phosphate nanoparticle vaccines to improve the efficacy of immunotherapy in patients with tumors and to provide new ideas and strategies for the field of tumor therapy.

Anti-Herpes zoster vaccination in patients with dermatologic diseases: a position statement from the Italian SIDeMaST group of sexually transmitted, infectious and tropical diseases

Herpes zoster (HZ) is a condition caused by the reactivation of varicella-zoster virus (VZV), the virus responsible for chickepox, which is the clinical manifestation of the primary infection. Congenital or acquired immune system deficiencies, as well as the physiological decline in immune response occurring in the elderly, known as immune senescence, can allow VZV reactivation and, consequently, HZ. One out of 3 people develops HZ during their lifetime. Moreover, thirty percent of the affected subjects develop post-herpetic neuralgia, the most frequent complication after HZ skin rash. Patients with dermatological conditions characterized by alteration of the immune system, such as systemic lupus erythematosus, psoriasis, atopic dermatitis, bullous diseases, and cutaneous lymphomas, are at higher risk of developing HZ and post-herpetic neuralgia, even when their disease is in remission. In the present work, we described the currently available vaccinations against HZ and provided recommendations for the vaccination against HZ in patients with dermatological diseases.

Improving Influenza Vaccination Coverage in Patients with Cancer: A Position Paper from a Multidisciplinary Expert Group

Patients with cancer can be immunocompromised because of their disease and/or due to anticancer therapy. In this population, severe influenza virus infections are associated with an elevated risk of morbidity and mortality. Influenza vaccination is therefore highly recommended in cancer patients, including those receiving anticancer therapy. However, vaccination coverage remains far below the recommended target for vulnerable subjects. Six specialists in oncology, hematology, immunology, and public health/vaccinology convened with the objective of developing strategies, based on evidence and clinical experience, for improving influenza vaccination coverage in cancer patients. This viewpoint provides an overview of current influenza vaccination recommendations in cancer patients, discusses barriers to vaccination coverage, and presents strategies for overcoming said barriers. New immunization issues raised by the COVID-19 pandemic are also addressed. Future directions include improving public education on influenza vaccination, providing the media with accurate information, improving knowledge among healthcare professionals, improving access to vaccines for cancer patients, co-administration of the influenza and COVID-19 vaccines, increased collaboration between oncologists and other health professionals, increased accessibility of digital vaccination registries to specialists, shared information platforms, and promoting immunization campaigns by healthcare systems with the support of scientific societies.

Italian oncologists and vaccinations against infectious diseases: Results of a survey of the Italian Association of Medical Oncology

BACKGROUND

Patients with cancer present a higher risk of vaccine-preventable diseases. Recommended vaccinations are the most cost-effective measure to reduce the risk of transmission and related complications. Nevertheless, vaccination rates are inadequate. Oncologists have a central role in tailored vaccine communication to their patients. We present the results of a survey conducted by AIOM in 2022, focusing on the perception of the problem by oncologists.

MATERIALS AND METHODS

An anonymous 31-item online questionnaire was shared on 15 September 2022 on the AIOM website. The objectives of this survey were to examine the perception of Italian oncologists on vaccine-preventable diseases and the main available vaccines, their attitude towards recommending vaccines and the COVID-19 pandemic impact on their habits regarding vaccine-preventable diseases.

RESULTS

Between September 2022 and January 2023, 114 medical oncologists (5% of the members) completed the anonymous questionnaire. At the first oncological visit, only 30% of respondents usually propose a vaccination schedule to all their patient, 41% do not usually discuss vaccinations at the first visit and 29% recommend vaccines exclusively to specific categories of patients. For 56% of respondents, patients are more aware of the benefits of vaccines, whereas 36% reported that patients are worried of receiving too many vaccines.

CONCLUSION

This is the first survey conducted among Italian oncologists to better understand the perception and attitudes towards the vaccination. It highlights the urgent issues of educating and training oncologists in vaccine-preventable diseases and vaccine awareness and the need to build (or implement) a network of multidisciplinary collaborations.

Herpes zoster after the third dose of SARS-CoV-2 mRNA-BNT162b2 vaccine in actively treated cancer patients: a prospective study

Several concerns have been raised about a causal relationship between COVID-19 mRNA-based vaccines and the development of herpes zoster (HZ). We performed a prospective analysis of the Vax-On-Third-Profile study to investigate the incidence of HZ after the third dose of mRNA-BNT162b2 (tozinameran) and its correlation with immune responses. Patients who had received a booster dose and had been actively treated for at least 8 weeks were eligible. Serologic assessment was performed before the third dose of tozinameran (timepoint-1) and 4 weeks later (timepoint-2). We also assessed the incidence of SARS-CoV-2 breakthrough infections at predefined time points. The current analysis included 310 patients, of whom 109 (35.2%) and 111 (35.8%) were being treated with targeted therapies and cytotoxic chemotherapy, respectively. All participants received a third dose of tozinameran between September 26 and October 30, 2021. After a mean follow-up of 17.3 (IQR 15.1-18.4) months, HZ occurred in 8 recipients, for a cumulative incidence of 2.6%, and an incidence rate of 0.310 per person-year (95% CI 0.267-0.333). All HZ cases occurred within 30 days of booster dosing (range 5-29 days), with a median time to onset of 15 (IQR 9-22) days. Among the 7 patients (2.2%) who also contracted a SARS-CoV-2 infection, all cases preceded COVID-19 outbreaks. No instances of complicated HZ were reported. In multivariate analysis, impaired T helper and T cytotoxic cell counts independently correlated with HZ occurrence. These findings provide the first evidence that cancer patients on active treatment have a not negligible risk of developing HZ within 30 days after the third dose of tozinameran. The favorable clinical outcome of all observed cases confirms that protective effects of boosters in reducing the risk of severe COVID-19 outweigh the potential risk of HZ occurrence.

The immunogenicity and the safety of the adjuvanted glycoprotein E (gE)-based recombinant vaccine against herpes zoster (RZV) in cancer patients during immunotherapy

Herpes zoster (HZ) is caused by the reactivation of latent varicella zoster virus (VZV). Severe immunocompromising conditions, such as solid tumors, have been largely associated with an increased risk for HZ due to waning VZV-specific cellular immunity. With the approval of the adjuvanted glycoprotein E (gE)-based recombinant vaccine (RZV; Shingrix™, GSK) also in immunocompromised subjects, HZ is considered a vaccine-preventable disease changing perspectives in immunocompromised subjects. To date, no clinical trial has evaluated the immunogenicity in the patients with cancer undergoing immunotherapy. In this study, we describe the humoral and cell-mediated immune responses in 38 cancer patients treated with immune checkpoint inhibitors (ICIs) and receiving RZV. We used samples collected at baseline (T0), 3 weeks (T2), and 6 months (T3) after the complete RV vaccination schedule. Our data showed that a significant proportion (40,5%) of RZV recipients mounted a stronger humoral and cell-mediated immune response at 3 weeks (T2) after complete RZV vaccination schedule. Interestingly, both humoral and cell-mediated immune responses were mostly stable over 6 months (T3). Interestingly, the overall IFNγ-producing lymphocytes was mainly associated with CD4 T cell response (p = .0012). In conclusion, data from our pilot study suggest a strong and long-lasting immunogenicity of RZV in ICI-treated patients. Prospective analyses at 1 year after vaccination will be performed in order to evaluate the long-term persistence of humoral and cell-mediated response against RZV.

Hospitalization burden related to herpes zoster infection during the COVID-19 pandemic in Spain (2020-2021)

Varicella-Zoster Virus (VZV) belongs to the family Herpesviridae. Herpes zoster (HZ) is caused by reactivation of latent VZV. It is associated with risk factors such as immunosenescence, immunosuppressive pathologies and pharmacological treatments. Patients with these risk factors are more likely to be hospitalized. Increases in HZ hospitalizations have been reported in many countries in recent years. The objective of this study is to estimate hospitalization rates, mortality rates and costs due to HZ during the worst years of the COVID-19 pandemic in Spain (2020-2021). This is a descriptive study based on an analysis of information from the Minimum Basic Dataset and coded according to the Spanish version of the 10th International Classification of Diseases (ICD-10-CM). Hospitalization, mortality and case-fatality rates, and median length of hospitalization were calculated.. The hospitalization rate was 14.4 cases per 100,000 inhabitants, and the mortality rate was 1.3 cases per 100,000 inhabitants. Both increased considerably with age. In this time period, 92.3% of the registered cases were people over 50 years of age. Nevertheless, during the COVID-19 pandemic period, hospitalization rate decreased and the mortality rate increased from previous years. HZ hospitalization and mortality rates are relevant issues in the public health of older people. It is highly recommended to evaluate new vaccination strategies against VZV to include the HZ vaccine for health care for elderly people, as well as to reduce the disease burden and associated risk factors. The estimation of HZ disease hospitalization costs were €100,433,904.

Vaccination for seasonal flu, pneumococcal infection, and SARS-CoV-2 in patients with solid tumors: recommendations of the Associazione Italiana di Oncologia Medica (AIOM)

Patients with cancer have a well-known and higher risk of vaccine-preventable diseases (VPDs). VPDs may cause severe complications in this setting due to the immune system impairment, malnutrition and oncological treatments. Despite this evidence, vaccination rates are inadequate. The Italian Association of Medical Oncology (AIOM) has been involved in vaccination awareness since 2014. Based on a careful review of the available data about the immunogenicity, effectiveness and safety of flu, pneumococcal and anti-SARS-CoV-2 vaccines, we report the recommendations of the Associazione Italiana di Oncologia Medica about these vaccinations in adult patients with solid tumors. AIOM recommends comprehensive education on the issue of VPDs. We believe that a multidisciplinary care model may improve the vaccination coverage in immunocompromised patients. Continued surveillance, implementation of preventive practices and future well-designed immunological prospective studies are essential for a better management of our patients with cancer.