Live Attenuated Infl uenza Vaccine
16.7.6 Hepatitis B Virus Vaccine
In areas of high prevalence, especially East Asia and lower-income countries, the risk of HBV transmission during chemotherapeutic regimens is signifi cant and therefore vaccination in these settings should be strongly considered Somjee et al. 1999 ; Meral et al. 2000 ; Sevinir et al. 2003 ; Yetgin et al. 2007 . Multiple studies using differ- ent vaccination schedules, a combination of pas- sive and active immunization, and signifi cant difference in transmission risk are present in the literature Berberoğlu et al. 1995 ; Hovi et al. 1995 ; Kavakli et al. 1996 ; Goyal et al. 1998 ; Somjee et al. 1999 ; Meral et al. 2000 ; Yetgin et al. 2001 ; Somjee et al. 2002 ; Köksal et al. 2007 ; Yetgin et al. 2007 ; Baytan et al. 2008 . The lowest rate of HBV transmission appears to be in those patients that receive a combination of passive and active immunization although the cost- effectiveness of this approach is question- able Kavakli et al. 1996 ; Meral et al. 2000 ; Somjee et al. 2002 . For seronegative patients with ALL in maintenance, seroconversion rates ranged from 35.1–62.5 after a 2–5 shot HBV series Yetgin et al. 2001 , 2007 ; Baytan et al. 2008 . Although HBV transmission still occurs in those that are immunized during therapy, Yetgin et al. 2007 showed that infection was signifi cantly decreased compared to unvacci- nated patients, even if seroconversion did not occur. Additional studies among pediatric oncol- ogy patients with variable timing of immuniza- tion and vaccination schedules showed a seroconversion rate of 50–78 Berberoğlu et al. 1995 ; Hovi et al. 1995 ; Köksal et al. 2007 . Hovi et al. 1995 studied 165 pediatric oncology patients; of the 51 on therapy, 67 responded to a three-dose immunization schedule as compared to a 97 seroresponse in the 114 off therapy. HBV immunization is important in settings out- side of the United States and Western Europe where risk of transmission during therapy is high, although fi rm recommendations on the optimal timing and schedule of vaccination cannot be made based on the studies to date.16.7.7 Meningococcal Conjugate Vaccine
The risk of meningococcus in immunocompro- mised pediatric oncology patients is unknown. Yu et al. 2007 studied vaccine response to protein- conjugated meningococcal C vaccine in 25 children with ALL and found improved response in those vaccinated 3 months after the completion of chemotherapy as compared to those in maintenance therapy 4 of 15 responders in maintenance versus 9 of 10 responders after chemotherapy completion.16.7.8 Varicella Zoster Virus
Due to the herd immunity provided by routine varicella vaccination, especially in North America, guidelines for immunization during ALL mainte- nance have changed, and immunization is no lon- ger recommended in these settings Centers for Disease Control and Prevention 2007 ; American Academy of Pediatrics 2012c ; Caniza et al. 2012 . However, varicella immunization should still be a consideration in higher- risk populations, especially lower-income countries and, potentially, those higher income countries without universal varicella vaccination campaigns Levin 2008 ; Esposito et al. 2010a . Sartori 2004 provides an excellent review of varicella vaccination in immunocompromised patients. Early studies of the effi cacy and safety of live attenuated varicella vaccine in children with acute leukemia were done in Japan with fur- ther safety data in the United States Gershon et al. 1984 ; Takahashi et al. 1985 ; Gershon et al. 1986 ; Gershon and Steinberg 1989 . In their initial study, Gershon et al. 1984 showed the safety of live attenuated varicella vac- cination when given to children with ALL that were in continuous clinical remission for 1 year, had a lymphocyte count ≥0.7 x 10 9 L, an IgG level ≥100 mgdL, responded to at least one mitogen, and had all chemotherapy suspended for 1 week before and after vaccination. Seroresponse was 80 after one dose of VZV. Rash was the only side effect which also increased seroconversion as well as the chance of transmission. Vaccination was quite protective, decreasing rate of infection after exposure to 18 from an expected 90 and also presenting as mild disease in those with clini- cal illness after exposure. A follow-up study by the same group with a larger cohort showed 88 seroconversion after one dose of vaccination and 98 seroconversion after two doses with no nota- ble serious adverse events Gershon and Steinberg 1989 . Multiple other small studies have shown similar results with no serious adverse events Heath and Malpas 1985 ; Ninane et al. 1985 ; Heath et al. 1987 ; Ecevit et al. 1996 ; Cakir et al. 2012 . A recent case report by Schrauder et al. 2007 on a child with ALL who developed fulminant varicella infection 32 days after varicella vacci- nation deserves mention. Vaccination was given with an interruption in chemotherapy, 1 week prior and 1 week after, but was given 5 months after complete remission had been achieved and prior to intensive reinduction chemotherapy, not in accordance with the stringent guidelines set forth by Takahashi et al. 1985 and Gershon et al. 1984 , 1986 ; Gershon and Steinberg 1989 . Based on their case, the authors recommend waiting at least 9 months after all therapy completion including maintenance chemother- apy prior to administering varicella vaccination. Their recommendation is not supported by the existing literature but does emphasize the care and attention that is necessary when administer- ing this live attenuated vaccine to children that remain immunocompromised Centers for Disease Control and Prevention 2007 .16.8 Recommendations
for Vaccination After Chemotherapy Completion Immune reconstitution is variable after the com- pletion of chemotherapy leading to inconsistent guidelines for revaccination. Among the pub- lished guidelines, four authors recommend com- mencing revaccination 3 months after therapy completion Centers for Disease Control and Prevention 1993 ; Sung et al. 2001 ; Allen 2007 ; Esposito et al. 2010a . For three of the four authors, this recommendation is inclusive of live viral vaccines Centers for Disease Control and Prevention 2007 . Esposito et al. 2010a recom- mend waiting 6 months for live vaccines. The UK guidelines Royal College of Paediatrics and Child Health 2002 recommend waiting 6 months for all vaccinations while Ruggiero et al. 2011 recommend waiting 6 months for inactivated killed vaccines and measles but 12 months for VZV. Fioredda et al. 2005 also recommend waiting 6 months after therapy completion. Guidelines are unclear in regard to children that interrupted their primary immunization series Esposito et al. 2010a ; Ruggiero et al. 2011 . Based on their review, van Tilburg et al. 2012 conclude that although revaccination is important, further study is still required to determine what the appropriate immunizations are, depending on the local herd immunity and risk for vaccine- preventable disease after chemotherapy. They do feel based on their review that 3 months after the completion of therapy is a good time point to begin the evaluatory process. Whether the evalu- atory process should include pre- andor post- immunization titers is also unclear; additionally there is a signifi cant associated cost with such a strategy and seroprotection may not alwaysParts
» Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Introduction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» History and Physical Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Defi ning the Risk for Serious
» Initial Laboratory Evaluation Diagnostic Evaluation
» Chest Radiography CXR A supine CXR may identify pleural effusions,
» Computed Tomography CT Radiographic Imaging
» Magnetic Resonance Imaging MRI
» Positron Emission Tomography PET
» Aspergillus Galactomannan GMN Biomarkers for Invasive
» 1,3-β- Biomarkers for Invasive
» Polymerase Chain Reaction PCR
» Viral Studies Diagnostic Evaluation
» Invasive Procedures: Diagnostic Evaluation
» Adult FN Guidelines Empiric Management
» Monotherapy Versus Combination Therapy
» Which Monotherapy to Choose A Cochrane review of antipseudomonal beta-
» Alterations in Initial Empiric FN Antibiotic Management
» Outpatient Management of FN Although there remains a lack of one uniform
» Choice of Empiric Antifungal Therapy
» Duration of Antimicrobial Empiric Management
» Endovascular Sources Empiric Management
» Adjunctive Treatment Empiric Management
» Emergence of Resistant Empiric Management
» Red Blood Cell Administration
» Granulocyte Transfusion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hemolytic Transfusion Risks of Blood Product
» Infection and Sepsis Risks of Blood Product
» Allergic Reactions Risks of Blood Product
» Febrile Nonhemolytic Risks of Blood Product
» Transfusion-Related Acute Risks of Blood Product
» Transfusion-Associated Risks of Blood Product
» Iron Overload Risks of Blood Product
» Laboratory Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» General Management Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Alkalinization Urinary alkalinization has been a long-standing
» Allopurinol Allopurinol inhibits xanthine oxidase, an enzyme
» Rasburicase Rasburicase, recombinant urate oxidase, converts
» Renal Interventions Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pathophysiology Superior Vena Cava
» History and Physical Exam SVCSSMS should be suspected in a patient
» Imaging Studies The diagnosis of SVCSSMS is often made on
» Other Studies Tissue is required to make a defi nitive diagnosis
» Treatment Superior Vena Cava
» History and Physical Exam Small pericardial effusions are frequently asymp-
» Imaging and Other Studies The presence of a pericardial effusion can be
» History and Physical Exam Many patients with small pleural effusions are
» Imaging Studies When a pleural effusion is suspected, a chest
» History and Physical Exam Patients with pheochromocytoma typically have
» Laboratory Studies The diagnosis of pheochromocytoma is best made
» Imaging Studies Clinical Presentation
» Pulmonary Leukostasis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Presentation Spinal Cord Compression
» Differential Diagnosis Spinal Cord Compression
» Imaging MRI of the spine can help narrow the differential
» Surgery Surgery in spinal cord compression can be uti-
» Radiation Therapy The advantages of external beam radiation ther-
» Outcomes Spinal Cord Compression
» Presentation Altered Mental Status
» Initial Management Altered Mental Status
» Metabolic The metabolic causes of AMS or seizure in pedi-
» Chemotherapy-Associated Neurotoxicity Differential Diagnosis
» Posterior Reversible Encephalopathy Syndrome
» Outcomes Altered Mental Status
» Initial Management Increased Intracranial
» Soft Tissue A large meta-analysis of published data suggests
» Cerebrospinal Fluid Hydrocephalus is an excess of CSF within the
» Hemorrhage and Thrombosis Differential Diagnosis
» Idiopathic Intracranial Hypertension Differential Diagnosis
» Presentation of Stroke Cerebrovascular Disease
» Differential Diagnosis Cerebrovascular Disease
» Etiology of Stroke in Pediatric
» Ischemic Stroke After an ischemic stroke is diagnosed, the patient
» Hemorrhagic Stroke Hematomas can expand over several hours from
» Acute Lymphoblastic Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Myelogenous Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Promyelocytic Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Chronic Myelogenous Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Tumor Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Leukapheresis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hyperhydration Other Treatment Modalities
» Hydroxyurea Other Treatment Modalities
» Cranial Irradiation Other Treatment Modalities
» Pseudohyperkalemia Hyperleukocytosis has been noted to cause pseudo-
» Pseudohypoxemia Due to the rapid consumption of oxygen by leu-
» Pseudohypoglycemia Consumption of glucose by excess leukocytes
» Pseudothrombocytosis Leukemic blast lysis can lead to cell fragmenta-
» Transfusion Practice with Other Supportive Care
» Anesthetic Procedures Other Supportive Care
» Neutropenic Enterocolitis Gastrointestinal Infection
» Perirectal Abscess Gastrointestinal Infection
» Gastrointestinal Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pancreatitis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Bowel Obstruction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Abdominal Compartment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» ALL Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Other Malignancies Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Central Venous Catheters Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diagnosis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nociceptive Pain Types of Pain
» Neuropathic Pain Types of Pain
» World Health Organization Pharmacologic Treatment
» Intermittent Opioid Use Pharmacologic Treatment
» Long-Acting Opioids Pharmacologic Treatment
» Breakthrough Dosing Pharmacologic Treatment
» Opioid Rotation Pharmacologic Treatment
» Patient-Controlled Analgesia Pharmacologic Treatment
» Constipation Side Effects of Opioids
» Nausea and Vomiting Nausea and vomiting are rare opioid side effects
» Pruritus Pruritus is a common side effect of opioid use
» Sedation Side Effects of Opioids
» Confusion and Agitation Renal and hepatic function should be checked
» Respiratory Depression When dosed appropriately, opioids rarely result
» Myoclonus Patients receiving very high doses of opioids for
» Urinary Retention Urinary retention can be caused by any opioid but
» Calcium Channel Blockers Neuropathic Pain
» Serotonin and Norepinephrine Neuropathic Pain
» Tricyclic Antidepressants Neuropathic Pain
» Interventional Techniques Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vincristine-Related Peripheral Oncology-Specifi c Pain
» Osteonecrosis Oncology-Specifi c Pain
» Post-lumbar Puncture Oncology-Specifi c Pain
» Mucositis Pain Oncology-Specifi c Pain
» Pathophysiology of Emesis Chemotherapy-Induced
» Principles of Emesis Control in the Cancer Patient
» Emetogenicity of Chemotherapy Chemotherapy-Induced
» Dopamine Receptor Antagonists Classes of Antiemetics
» Corticosteroids Classes of Antiemetics
» Cannabinoids The plant Cannabis contains more than 60 differ-
» Other Antiemetic Agents Antihistamines
» Alternative Therapies Ginger Classes of Antiemetics
» Management of CINV Management of CINV Table
» Special Considerations Anticipatory Nausea and Vomiting
» Radiation-Induced Nausea Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Initiation The initiation stage occurs immediately following
» Primary Damage Response Pathophysiology of Oral Mucositis
» Signal Amplifi cation Pathophysiology of Oral Mucositis
» Ulceration Ulceration is the phase with the most clinical sig-
» Healing Pathophysiology of Oral Mucositis
» Clinical Course of Oral Mucositis
» Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Palifermin Prevention and Treatment
» Low-Level Laser Therapy Prevention and Treatment
» Glutamine Prevention and Treatment
» Cryotherapy Prevention and Treatment
» Oral Care Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Infections Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nutrition Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Dietary Counseling Nutrition Intervention
» Appetite Stimulants Nutrition Intervention
» Enteral Tube Feeding Nutrition Intervention
» Parenteral Nutrition Nutrition Intervention
» Nutrition and Survivorship Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Neutropenia Hematologic Toxicity
» Management of Thrombocytopenia Hematologic Toxicity
» Management of Anemia Hematologic Toxicity
» Somnolence Syndrome Central Nervous System
» Lhermitte’s Sign Central Nervous System
» Skin Complications Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Mucositis Head and Neck
» Ear Complications Head and Neck
» Laryngeal Complications Head and Neck
» Dysphagia and Esophagitis Gastrointestinal
» Nausea, Vomiting and Anorexia
» Pneumonitis Major Organ Infl ammation
» Pericarditis Major Organ Infl ammation
» Hepatitis Major Organ Infl ammation
» Nephropathy Major Organ Infl ammation
» Cystitis Major Organ Infl ammation
» Risk Stratifi cation Prevention of Bacterial
» Adult Data Antimicrobial Approaches
» Pediatric Data Data regarding the utility of bacterial prophylaxis
» Risks of Prophylaxis Prevention of Bacterial
» Guidelines and Current Usage of Antibacterial Prophylaxis
» Protocols for Line Placement and Care
» Antibiotic and Ethanol Locks
» Chlorhexidine Cleansing Chlorhexidine gluconate CHG is a bactericidal
» Future Directions Prevention of Bacterial
» Risk Stratifi cation Prevention of Fungal
» Approaches to Antifungal Prophylaxis
» Guideline Recommendations for Antifungal Prophylaxis
» Limitations of Current Options for Antifungal Prophylaxis
» Risks of Prophylaxis Prevention of Fungal
» Biomarkers Prevention of Fungal
» Future Directions Prevention of Fungal
» Risk Stratifi cation Prevention of Pneumocystis
» Approaches to PCP Prophylaxis
» Summary of the Recommendations
» Future Directions Prevention of Pneumocystis
» Postexposure Chemoprophylaxis Prevention of Viral Infections
» Suppressive Therapy Prevention of Viral Infections
» Future Directions Prevention of Viral Infections
» Hand Hygiene Infection Control Practices
» Mandatory Vaccination Infection Control Practices
» Hospital Isolation Practices Infection Control Practices
» Visitor Screening Policies Infection Control Practices
» Work Restriction Infection Control Practices
» Cytomegalovirus CMV Status of Transfused Blood
» Treatment of Myelosuppression with
» Prevention of Febrile Neutropenia, Delay
» Treatment of Febrile Neutropenia
» Treatment of Myelosuppression Clinical Usage of Myeloid Growth Factors
» Comparison of Granulocyte Colony-Stimulating Factor
» Optimal Dosing Adult guidelines recommend dosing of 5 mcgkg
» Route of Administration Optimal Administration of Colony-Stimulating Factors
» Optimal Timing Optimal Administration of Colony-Stimulating Factors
» Erythropoietin Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Interleukin-11 Platelet Growth Factors
» Thrombopoietin Receptor Agonists Platelet Growth Factors
» Immune Status Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Status During Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Recovery After Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immunization Practice Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diphtheria, Tetanus, and Acellular Pertussis
» Pneumococcal Conjugate Vaccine Recommendations
» Hemophilus Infl uenzae Type b
» Inactivated Infl uenza Vaccine Although in a Cochrane review Goossen et al.
» 2009 H1N1 Pandemic Vaccine Seven studies have reported on effi cacy of the
» Live Attenuated Infl uenza Vaccine
» Meningococcal Conjugate Vaccine Recommendations
» Varicella Zoster Virus Recommendations
» Recommendations Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Treatment of Hypogammaglobulinemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vaccination of Household Contacts
» Peripherally Inserted Central Catheter
» External Tunneled Central Venous Catheter
» Implanted Port Types of Central Venous
» Catheter Insertion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Exit Site Infection Infection
» Prevention of Infection Infection
» Drug Precipitate or Lipid Residue Occlusion Thrombotic Occlusion
» Evaluation of Catheter- Related Thrombosis
» Treatment of Catheter- Related Thrombosis
» Special Considerations During Anticoagulation Therapy
» Contraindications of Anticoagulant Therapy
» Skin Antisepsis Catheter Maintenance
» Central Venous Catheter Dressings
» Hub Care Catheter Maintenance
» Central Venous Catheter Flushing and Locking
» Chlorhexidine Bathing Chlorhexidine has been shown to be effective in
» Antiseptic Needleless Connectors and Antiseptic
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