Current recommendations for immunization in children with cancer: A narrative review
DOI:
https://doi.org/10.31305/rrijm.2026.v11.n05.024Keywords:
Cancer, Child, Chimeric antigen receptor T-cell therapy, Immune check point inhibitors, Janus kinase inhibitors, Monoclonal antibodies, Recommendations, Standard-dose chemotherapy, VaccinationAbstract
Pediatric cancers are one of the leading causes of death by disease among children world-wide, with non-cancer related morbidity and mortality burden due to vaccine preventable diseases being disproportionately high in developing countries. Besides standard-dose chemotherapy, groundbreaking therapeutic approaches - Monoclonal antibodies (MA), small molecule Janus kinase inhibitors (JKI), Chimeric antigen receptor T cell (CAR-T Cell) Therapy and Immune check point inhibitors (ICI) - have revolutionized oncology. This narrative review, collated until April 2026, elucidates key principles and enumerates relevant immunization strategies recommended by leading international bodies. The Infectious Diseases Society of America (IDSA) 2013 and Italian Association Paediatric Haematology Oncology (AIEOP) 2025 guidelines recommend ‘only routine immunization/continuation with boosters’ (resuming the schedule starting from the suspended dose) starting 3-6 months after chemotherapy completion. In contrast, the British ‘The Children and Young People's Cancer Association’ (CCLG) 2026 and Australian Immunization Handbook 2026 guidelines explicitly recommend revaccination with a single dose (even if the series had been completed prior to chemotherapy), commencing 3 months after chemotherapy completion. Live vaccines are contraindicated during cancer therapy. Live vaccines should be administered at least 4 weeks prior to commencing treatment with MA. Due to strong immunosuppressive effects on B-cells and hypogammaglobulinemia, for Blinantunomab [Anti-CD19], Inotuzumab-ozogamicin [Anti-CD22], Rituximab and Obinutuzumab [Anti-CD20], non-live vaccines are to be administered 6 months after stopping therapy, while live vaccines can be administered 12 months later. For Brentuximab-vedotin [Anti-CD30] and Gentuzumab-ozogamicina [Anti-CD33], non-live vaccines are to be administered 4 and 5 weeks respectively after stopping therapy, while live vaccines can be administered 3 months later. Live vaccines are recommended 2-4 weeks before or at least 3 months after JKI therapy ends. Live vaccines should be administered at least 4 weeks before commencing pre-CAR-T conditioning regimens. Non-live vaccines are to be administered at least 3 months after stopping CAR-T regimen. Live vaccines can be administered after 12 months provided there is evidence of immune restitution (CD19+ or CD20+ B cells > 0.2 × 109/L and CD4+ T cells > 0.2 × 109/L), evidence of detectable IgA, and at least 8 months since the last intravenous immunoglobulin dose. All live vaccines must be completed 4 weeks before the first ICI infusion, or administered at least 3 months after the final ICI dose. Routine sibling/contact vaccinations should continue except for oral poliomyelitis vaccine, which is contraindicated.
References
1. Steliarova-Foucher E, Colombet M, Ries LAG, et al. International incidence of childhood cancer, 2001–10: a population-based registry study. Lancet Oncol 2017; 18: 719–731. DOI: https://doi.org/10.1016/S1470-2045(17)30186-9
2. Cayrol J, Ilbawi A, Sullivan M, et al. The development and education of a workforce in childhood cancer services in low- and middle-income countries: a scoping review protocol. Syst Rev 2022; 11: 167. DOI: https://doi.org/10.1186/s13643-022-02040-0
3. Lupo PJ, Spector LG. Cancer Progress and Priorities: Childhood Cancer. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol 2020; 29: 1081–1094. DOI: https://doi.org/10.1158/1055-9965.EPI-19-0941
4. Childhood cancer, https://www.who.int/news-room/fact-sheets/detail/cancer-in-children (accessed 19 May 2026).
5. Esposito S, Cecinati V, Brescia L, et al. Vaccinations in children with cancer. Vaccine 2010; 28: 3278–3284. DOI: https://doi.org/10.1016/j.vaccine.2010.02.096
6. Immunization Guidelines for Children with Cancer in India, https://www.indianpediatrics.net/dec2019/dec-1009-1010.htm (accessed 23 September 2025). DOI: https://doi.org/10.1007/s13312-019-1672-6
7. van Thiel Berghuijs KM, Kaddas HK, Warner EL, et al. Vaccination practices of pediatric oncologists from eight states. BMC Health Serv Res 2023; 23: 1215. DOI: https://doi.org/10.1186/s12913-023-10160-z
8. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host. Clin Infect Dis 2014; 58: e44–e100. DOI: https://doi.org/10.1093/cid/cit684
9. Sharon JA, Richard JP, Kiruthika S, et al. Vaccination in Pediatric Movement Disorders, Immune-mediated/ Inflammatory Central Nervous System Disorders, and Developmental and Epileptic Encephalopathies: Current Evidence-Based Recommendations. Res Rev Int J Multidiscip 2025; 10: 80–91. DOI: https://doi.org/10.31305/rrijm.2025.v10.n11.009
10. Sung L, Heurter H, Zokvic KM, et al. Practical vaccination guidelines for children with cancer. Paediatr Child Health 2001; 6: 379–383. DOI: https://doi.org/10.1093/pch/6.6.379
11. Mackall CL. T-cell immunodeficiency following cytotoxic antineoplastic therapy: a review. The Oncologist 1999; 4: 370–378. DOI: https://doi.org/10.1634/theoncologist.4-5-370
12. Childhood Acute Lymphoblastic Leukemia Treatment (PDQ®) - NCI, https://www.cancer.gov/types/leukemia/hp/child-all-treatment-pdq (2026, accessed 19 May 2026).
13. Mustafa MM, Buchanan GR, Winick NJ, et al. Immune recovery in children with malignancy after cessation of chemotherapy. J Pediatr Hematol Oncol 1998; 20: 451–457.
14. Shetty AK, Winter MA. Immunization of Children Receiving Immunosuppressive Therapy for Cancer or Hematopoietic Stem Cell Transplantation. Ochsner J 2012; 12: 228–243.
15. Purple Book 2025 | Indian Academy of Pediatrics (IAP), https://iapindia.org/purple-book-2025/ (accessed 19 May 2026).
16. Canada PHA of. Immunization of immunocompromised persons: Canadian Immunization Guide, https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-3-vaccination-specific-populations/page-8-immunization-immunocompromised-persons.html (2007, accessed 19 May 2026).
17. CDC. Altered Immunocompetence. Vaccines & Immunizations, https://www.cdc.gov/vaccines/hcp/imz-best-practices/altered-immunocompetence.html (2026, accessed 19 May 2026).
18. Alanko S, Pelliniemi TT, Salmi TT. Recovery of blood B-lymphocytes and serum immunoglobulins after chemotherapy for childhood acute lymphoblastic leukemia. Cancer 1992; 69: 1481–1486. DOI: https://doi.org/10.1002/1097-0142(19920315)69:6<1481::AID-CNCR2820690628>3.0.CO;2-L
19. Ek T, Mellander L, Andersson B, et al. Immune reconstitution after childhood acute lymphoblastic leukemia is most severely affected in the high risk group. Pediatr Blood Cancer 2005; 44: 461–468. DOI: https://doi.org/10.1002/pbc.20255
20. Mackall CL, Fleisher TA, Brown MR, et al. Distinctions between CD8+ and CD4+ T-cell regenerative pathways result in prolonged T-cell subset imbalance after intensive chemotherapy. Blood 1997; 89: 3700–3707. DOI: https://doi.org/10.1182/blood.V89.10.3700
21. Mackall CL, Fleisher TA, Brown MR, et al. Age, thymopoiesis, and CD4+ T-lymphocyte regeneration after intensive chemotherapy. N Engl J Med 1995; 332: 143–149. DOI: https://doi.org/10.1056/NEJM199501193320303
22. Mustafa MM, Buchanan GR, Winick NJ, et al. Immune recovery in children with malignancy after cessation of chemotherapy. J Pediatr Hematol Oncol 1998; 20: 451–457. DOI: https://doi.org/10.1097/00043426-199809000-00008
23. Roederer M, De Rosa SC, Watanabe N, et al. Dynamics of fine T-cell subsets during HIV disease and after thymic ablation by mediastinal irradiation. Semin Immunol 1997; 9: 389–396. DOI: https://doi.org/10.1006/smim.1997.0097
24. George AJT, Ritter MA. Thymic involution with ageing: obsolescence or good housekeeping? Immunol Today 1996; 17: 267–272. DOI: https://doi.org/10.1016/0167-5699(96)80543-3
25. van Tilburg CM, Sanders E a. M, Rovers MM, et al. Loss of antibodies and response to (re-)vaccination in children after treatment for acute lymphocytic leukemia: a systematic review. Leukemia 2006; 20: 1717–1722. DOI: https://doi.org/10.1038/sj.leu.2404326
26. Ruggiero A, Battista A, Coccia P, et al. How to manage vaccinations in children with cancer. Pediatr Blood Cancer 2011; 57: 1104–1108. DOI: https://doi.org/10.1002/pbc.23333
27. Cesaro S, Giacchino M, Fioredda F, et al. Guidelines on Vaccinations in Paediatric Haematology and Oncology Patients. BioMed Res Int 2014; 2014: 707691.
28. Martire B, Beni A, Mastrototaro MF, et al. Vaccinations in Pediatric Hematology and Oncology: Biologic Basis, Clinical Applications, and Perspectives. Vaccines 2025; 13: 397. DOI: https://doi.org/10.3390/vaccines13040397
29. Top KA, Pham-Huy A, Price V, et al. Immunization practices in acute lymphocytic leukemia and post-hematopoietic stem cell transplant in Canadian Pediatric Hematology/Oncology centers. Hum Vaccines Immunother 2016; 12: 931–936. DOI: https://doi.org/10.1080/21645515.2015.1115165
30. Dr Soonie R.Patel, Professor Rod Skinner and Professor Paul T.Heath. Vaccinations For Paediatric Patients Treated With Standard-Dose Chemotherapy And Haemopoietic Stem Cell Transplantation (HSCT) Recipients, chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.piernetwork.org/uploads/4/7/8/1/47810883/vaccination_cclg_april2020.pdf (2022).
31. CCLG - The Children & Young People’s Cancer Association. Vaccination Guideline: For Children and Young People Treated for Cancer with Standard-Dose Chemotherapy and Haemopoietic Stem Cell Transplant (HSCT) | CCLG - The Children & Young People’s Cancer Association, https://www.cclg.org.uk/information-professionals/guidelines/vaccination-guideline-children-and-young-people-treated-cancer-with-standard-dose-chemotherapy (2026, accessed 25 May 2026).
32. Patel SR, Skinner R, Bate J, et al. Immunisation in children with cancer. Paediatr Child Health 2023; 33: 240–245. DOI: https://doi.org/10.1016/j.paed.2023.05.004
33. Cancer immunisation guideline: vaccine recommendations following chemotherapy and haematopoietic stem cell transplant. The Melbourne Vaccine Education Centre (MVEC), https://mvec.mcri.edu.au/references/cancer-immunisation-guideline-chemotherapy-and-post-haematopoietic-stem-cell-transplant_2/ (accessed 23 September 2025).
34. Patel SR, Chisholm JC, Heath PT. Vaccinations in Children Treated with Standard-Dose Cancer Therapy or Hematopoietic Stem Cell Transplantation. Pediatr Clin North Am 2008; 55: 169–186. DOI: https://doi.org/10.1016/j.pcl.2007.10.012
35. Moulik NR, Mandal P, Chandra J, et al. Immunization of Children with Cancer in India Treated with Chemotherapy - Consensus Guideline from the Pediatric Hematology-Oncology Chapter and the Advisory Committee on Vaccination and Immunization Practices of the Indian Academy of Pediatrics. Indian Pediatr 2019; 56: 1041–1048. DOI: https://doi.org/10.1007/s13312-019-1678-0
36. Indian Academy of Pediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP): Recommended Immunization Schedule (2023) and Update on Immunization for Children Aged 0 Through 18 Years., https://indianpediatrics.net/epub012024/FTA-00592.pdf (accessed 23 September 2025).
37. Mirsaeidi M, Schraufnagel DE. Pneumococcal Vaccines: Understanding Centers for Disease Control and Prevention Recommendations. Ann Am Thorac Soc 2014; 11: 980–985. DOI: https://doi.org/10.1513/AnnalsATS.201401-042CME
38. IAP Guidebook on Immunization | Indian Academy of Pediatrics (IAP), https://iapindia.org/iap-guidebook-on-immunization/ (accessed 23 September 2025).
39. Neemann KA, Sato AI. Vaccinations in children with hematologic malignancies and those receiving hematopoietic stem cell transplants or cellular therapies. Transpl Infect Dis 2023; 25: e14100. DOI: https://doi.org/10.1111/tid.14100
40. Cesaro S, Giacchino M, Fioredda F, et al. Guidelines on vaccinations in paediatric haematology and oncology patients. BioMed Res Int 2014; 2014: 707691. DOI: https://doi.org/10.1155/2014/707691
41. Domachowske J, Hamrén UW, Banu I, et al. Safety and Pharmacokinetics of Nirsevimab in Immunocompromised Children. Pediatrics 2024; 154: e2024066508. DOI: https://doi.org/10.1542/peds.2024-066508
42. Richard JP, Kiruthika S, Sharon JA, et al. Immunization in Pediatric Neurodevelopmental disorders: Current Evidence-Based Recommendations. Res Rev Int J Multidiscip 2025; 10: 24–34. DOI: https://doi.org/10.31305/rrijm.2025.v10.n10.002
43. Pizzo & Poplack’s Principles and Practice of Pediatric Oncology, https://www.wolterskluwer.com/en/solutions/ovid/pizzo--poplacks-principles-and-practice-of-pediatric-oncology-833 (accessed 26 May 2026).
44. Sherin VC, Neya AS, Kiruthika S, et al. Vaccination in Pediatric Hereditary and Genetic Neuromuscular disorders: Current Evidence-Based Recommendations. Res Rev Int J Multidiscip 2026; 11: 195–214. DOI: https://doi.org/10.31305/rrijm.2026.v11.n03.021
45. Rivera-Izquierdo M, Valero-Ubierna MDC, Nieto-Gómez P, et al. Vaccination in patients under monoclonal antibody treatment: an updated comprehensive review. Expert Rev Vaccines 2020; 19: 727–744. DOI: https://doi.org/10.1080/14760584.2020.1800462
46. Kiruthika S, Jessica AS, Richard JP, et al. Vaccination in Pediatric Autoimmune Neuromuscular Disorders: Current evidence-based recommendations. Res Rev Int J Multidiscip 2025; 10: 93–106. DOI: https://doi.org/10.31305/rrijm.2025.v10.n12.013
47. Obeagu EI. JAK2 in pediatric leukemia: mechanisms of pathogenesis and drug development – a narrative review. Ann Med Surg 2025; 87: 3410–3423. DOI: https://doi.org/10.1097/MS9.0000000000003180
48. Narbutt J, Żuber Z, Lesiak A, et al. Vaccinations in Selected Immune-Related Diseases Treated with Biological Drugs and JAK Inhibitors—Literature Review and Statement of Experts from Polish Dermatological Society. Vaccines 2024; 12: 82. DOI: https://doi.org/10.3390/vaccines12010082
49. Reynolds G, Hall VG, Teh BW. Vaccine schedule recommendations and updates for patients with hematologic malignancy post-hematopoietic cell transplant or CAR T-cell therapy. Transpl Infect Dis Off J Transplant Soc 2023; 25 Suppl 1: e14109. DOI: https://doi.org/10.1111/tid.14109
50. Hill JA, Seo SK. How I prevent infections in patients receiving CD19-targeted chimeric antigen receptor T cells for B-cell malignancies. Blood 2020; 136: 925–935. DOI: https://doi.org/10.1182/blood.2019004000
51. Hayden PJ, Roddie C, Bader P, et al. Management of adults and children receiving CAR T-cell therapy: 2021 best practice recommendations of the European Society for Blood and Marrow Transplantation (EBMT) and the Joint Accreditation Committee of ISCT and EBMT (JACIE) and the European Haematology Association (EHA). Ann Oncol Off J Eur Soc Med Oncol 2022; 33: 259–275. DOI: https://doi.org/10.1016/j.annonc.2021.12.003
52. Bishop MR. Late complications and long-term care of adult CAR T-cell patients. Hematology 2024; 2024: 109–115. DOI: https://doi.org/10.1182/hematology.2024000534
53. Shahid Z, Jain T, Dioverti V, et al. Best Practice Considerations by The American Society of Transplant and Cellular Therapy: Infection Prevention and Management After Chimeric Antigen Receptor T Cell Therapy for Hematological Malignancies. Transplant Cell Ther 2024; 30: 955–969. DOI: https://doi.org/10.1016/j.jtct.2024.07.018
54. Secondary (acquired) immunodeficiency due to medical conditions | The Australian Immunisation Handbook, https://immunisationhandbook.health.gov.au/contents/vaccination-for-special-risk-groups/vaccination-for-people-who-are-immunocompromised/secondary-acquired-immunodeficiency-due-to-medical-conditions (2025, accessed 23 September 2025).
55. Chong CR, Park VJ, Cohen B, et al. Safety of Inactivated Influenza Vaccine in Cancer Patients Receiving Immune Checkpoint Inhibitors. Clin Infect Dis 2020; 70: 193–199. DOI: https://doi.org/10.1093/cid/ciz202
56. Sanft T, Day A, Ansbaugh S, et al. NCCN Guidelines® Insights: Survivorship, Version 1.2023. J Natl Compr Cancer Netw JNCCN 2023; 21: 792–803. DOI: https://doi.org/10.6004/jnccn.2023.0041
57. Keam B, Kang CK, Jun KI, et al. Immunogenicity of Influenza Vaccination in Patients with Cancer Receiving Immune Checkpoint Inhibitors. Clin Infect Dis Off Publ Infect Dis Soc Am 2020; 71: 422–425. DOI: https://doi.org/10.1093/cid/ciz1092
58. New J, Shenton L, Ksayer R, et al. Immune Checkpoint Inhibitors and Vaccination: Assessing Safety, Efficacy, and Synergistic Potential. Vaccines 2024; 12: 1270. DOI: https://doi.org/10.3390/vaccines12111270
59. Fakhraei H, Khalilzadeh S, Khanbabaei G, et al. Current Recommendations for Pneumococcal Vaccination of Children and Adults. Tanaffos 2015; 14: 161–164.
60. CDC. Summary of Risk-based Pneumococcal Vaccination Recommendations. Pneumococcal Disease, https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/risk-indications.html (2026, accessed 19 May 2026).
