The optimal vaccination strategy depends on several factors, including:

• Type and stage of malignancy
• Age of the patient
• Vaccination history
• Treatment modality
• Degree of immunosuppression
• Asplenia or stem cell transplantation

People with cancer, particularly those with hematological malignancies or advanced disease, often experience significant immune dysfunction as a result of both their disease and treatment.

Immunosuppression may result from:

• Chemotherapy
• Radiotherapy
• Corticosteroids
• Biologic therapies
• Anti-B-cell therapies (e.g., rituximab)
• Immune-modulating agents
• Cancer immunotherapy
• Functional or anatomical asplenia

Patients receiving chemotherapy or radiation therapy for leukemia, lymphoma, multiple myeloma, or solid tumors should generally be considered immunocompromised.

Vaccination Before Cancer Treatment

Whenever feasible, all indicated vaccines should be administered before:

• Chemotherapy
• Radiotherapy
• Immunosuppressive therapy
• Elective splenectomy

Timing of Vaccination

Inactivated Vaccines

• Ideally administered at least 2 weeks before immunosuppressive therapy.
• May be administered during chemotherapy if necessary.
• Vaccination during treatment is safe but may result in reduced immune responses.

Live Attenuated Vaccines

• Should be administered at least 4 weeks before immunosuppressive therapy.
• Are generally contraindicated during active treatment and significant immunosuppression.
• May be considered at least 3–12 months after completion of chemotherapy if immune recovery has occurred.

Vaccination during chemotherapy may be necessary in some situations, particularly when delaying vaccination would leave the patient vulnerable to infection.

Although vaccine responses may be suboptimal, inactivated vaccines remain safe and may provide meaningful protection.

Severe Neutropenia

Patients with severe neutropenia (absolute neutrophil count <0.5 × 10⁹/L) should generally defer vaccination until recovery to avoid confusion with treatment-related febrile episodes.

Why Influenza Vaccination Is Important

Influenza can cause significant morbidity and mortality in cancer patients, including:

• Secondary bacterial pneumonia
• Respiratory failure
• Hospitalization
• Death

Annual influenza vaccination is recommended for all cancer patients aged 6 months and older.

Vaccine Type

Timing

Optimal timing includes:

• At least 2 weeks before chemotherapy
• Between chemotherapy cycles
• Approximately 2 weeks after chemotherapy
• Avoiding periods of expected nadir white blood cell counts

Because influenza is seasonal, vaccination should not be unnecessarily delayed when protection is needed.

Household Contacts

Family members and close contacts should also receive annual influenza vaccination to reduce the risk of transmission.

Patients with:

• Multiple myeloma
• Chronic lymphocytic leukemia
• Lymphoma
• Lung cancer
• Generalized malignancies

are at increased risk of invasive pneumococcal disease. Vaccination should ideally be administered before treatment begins.

Recommended Strategy

Current recommendations favor the use of pneumococcal conjugate vaccines because they induce superior immune responses compared with polysaccharide vaccines.

Depending on age and local recommendations, vaccination may include:

• PCV13, PCV15 or PCV20
• Followed by PPSV23 if indicated

Patients with hematological malignancies, functional asplenia, or other high-risk conditions may require individualized schedules.

Hepatitis B virus (HBV) reactivation is a recognized complication of chemotherapy and immunosuppressive therapy, particularly among patients receiving anti-CD20 therapies such as rituximab.

Recommendations

• Assess HBV status at the time of cancer diagnosis.
• Vaccinate susceptible individuals whenever possible.
• Monitor patients at risk for HBV reactivation.
• Consider post-vaccination serologic testing in selected high-risk individuals.

Immunity to tetanus, diphtheria, and pertussis may decline following cancer treatment. A booster dose of Tdap should be considered following completion of therapy according to age-appropriate recommendations.

HPV vaccination is recommended according to routine age-based schedules.

Recommendations

• Immunocompromised individuals should receive a 3-dose schedule

Immunosuppression is not a contraindication to HPV vaccination, although vaccine responses may be reduced.

Meningococcal vaccination is recommended for:

• Adolescents
• Individuals with complement deficiencies
• Patients with anatomic or functional asplenia
• Other high-risk groups

Patients with splenic dysfunction due to malignancy or splenic irradiation should follow recommendations for individuals with asplenia.

Hepatitis A vaccination is recommended for cancer patients with:

• Travel to endemic regions
• Occupational exposure
• Household exposure
• Other recognized risk factors

All immunocompromised adults with cancer aged 18 years and older are recommended to receive:

• Two doses of recombinant zoster vaccine (Shingrix)

The vaccine is non-live and can be safely administered to immunocompromised patients.

Patients receiving:

• Anti-B-cell therapies (e.g., rituximab)
• TNF inhibitors
• Immune modulators
• Cytokine inhibitors

may have impaired vaccine responses.

Recommendations

• Administer vaccines at least 2 weeks before therapy whenever possible.
• Delay live vaccines for at least 3–12 months after treatment.
• Delay both live and non-live vaccines for at least 6 months after anti-B-cell therapies, recognizing that longer intervals may sometimes be necessary.

Live vaccines are generally contraindicated in patients with:

• Active malignancy
• Ongoing chemotherapy
• Significant immunosuppression
• Poorly controlled disease

Examples include:

• MMR vaccine
• Varicella vaccine
• Live attenuated influenza vaccine
• Oral typhoid vaccine

After Completion of Therapy

Live vaccines may be considered when:

• At least 3–12 months have elapsed since chemotherapy
• The underlying malignancy is in remission
• Immune recovery has occurred
• The patient is no longer significantly immunocompromised

Patients with anatomical or functional asplenia are at increased risk of overwhelming infection caused by encapsulated bacteria.

Recommended Vaccines

• Pneumococcal vaccines
• Meningococcal vaccines (MenACWY and MenB)
• Hib vaccine

Whenever possible, vaccination should occur at least 2 weeks before elective splenectomy. Patients with persistent asplenia may require booster doses according to risk-based recommendations.

For more, please visit: Anatomic or Functional Asplenia

Patients who completed their primary vaccination schedule before cancer diagnosis generally retain some immune memory and can receive most recommended vaccines after recovery without routine pre-vaccination antibody testing.

For patients who are clinically well and in remission for at least 6 months after completion of therapy, the following booster vaccinations may be considered.

• Australian Government Department of Health. Table. Recommendations for vaccination in people who have received chemotherapy | The Australian Immunisation Handbook. https://immunisationhandbook.health.gov.au/resources/tables/table-recommendations-for-vaccination-in-people-who-have-received-chemotherapy
• Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. (PMC4685676). https://pmc.ncbi.nlm.nih.gov/articles/PMC4685676/
• Centers for Disease Control and Prevention. Altered Immunocompetence | Vaccines & Immunizations. https://www.cdc.gov/vaccines/hcp/imz-best-practices/altered-immunocompetence.html
• ASCO. Vaccination of Adults With Cancer: ASCO Guideline. J Clin Oncol. https://ascopubs.org/doi/10.1200/JCO.24.00032