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Before cancer treatment, the team should check which vaccines a person has had and bring them up to date, ideally two to four weeks before. Non-live vaccines such as the flu jab can still be given during treatment. Live vaccines, such as MMR, chickenpox and the nasal flu spray for the patient, must be avoided during treatment and for months after. Family vaccines protect the patient too.
ASCO (2024, adults) asks clinicians to determine vaccination status and bring newly diagnosed adults up to date on seasonal and age- and risk-based vaccines (moderate, strong), ideally 2 to 4 weeks before treatment, with non-live vaccines allowed during or after chemotherapy, immunotherapy, hormonal treatment, radiation or surgery (moderate, strong). The Green Book (UK, all ages) gives inactivated vaccines at least two weeks before immunosuppressive treatment where possible, and otherwise at any time with re-immunisation considered after recovery. Live vaccines are contraindicated in acute and chronic leukaemia and lymphoma, during and for 6 months after immunosuppressive chemotherapy or radiotherapy, for 12 months after immunosuppressive biologics such as rituximab, for 24 months after a stem cell transplant (and longer with GVHD or ongoing immunosuppression), and for 3 months after high-dose corticosteroids (above 40 mg prednisolone a day, or 2 mg/kg/day in children under 20 kg, for more than a week). Live attenuated nasal influenza vaccine cannot be given to patients with cancer (ASCO).
Revaccination after transplant starts at 6 to 12 months (influenza, COVID-19 and pneumococcal from 3 months), after CD19 or BCMA CAR-T no sooner than 3 months for influenza and COVID-19 and 6 months for other non-live vaccines (very low, weak), and after B-cell depleting therapy COVID-19 only, at 6 months (moderate, strong). Household contacts should be fully vaccinated, including MMR, varicella and rotavirus, with hand washing after nappy changes for rotavirus; contacts of severely immunocompromised patients such as transplant recipients in isolation get inactivated rather than live influenza vaccine. Children with immunodeficiency attending school do not need to be kept away when classmates are immunised. For children, ASCO does not apply (it covers 19 and over); the Indian Academy of Pediatrics advises against live vaccines during and up to 6 months after chemotherapy and recommends only annual inactivated influenza vaccine for all children during chemotherapy.
Why: People with cancer catch infections more easily and more severely, and vaccines work best before treatment weakens the immune system.
“Clinicians should determine vaccination status and ensure that adults newly diagnosed with cancer and about to start treatment are up to date on seasonal vaccines as well as age- and risk-based vaccines (see Tables 2-4)”
ASCO, Journal of Clinical Oncology 2024 · Evidence quality: moderate; strength of recommendation: strong
Why: The response is best before treatment, yet a non-live vaccine cannot cause infection and still gives some protection later.
“Vaccination should ideally precede any planned cancer treatment by 2-4 weeks. However, nonlive vaccines can be administered during or after chemotherapy or immunotherapy, hormonal treatment, radiation, or surgery”
ASCO, Journal of Clinical Oncology 2024 · Evidence quality: moderate; strength of recommendation: strong
Why: A weakened vaccine germ can multiply out of control when the immune system is suppressed.
“those who are receiving, or have received in the past 6 months, immunosuppressive chemotherapy or radiotherapy for malignant disease or non-malignant disorders”
Why: B-cell depleting antibodies weaken immunity for longer than chemotherapy does.
“those who are receiving or have received in the past 12 months immunosuppressive biological therapy (e.g. anti-TNF therapy such as alemtuzumab, ofatumumab and rituximab) unless otherwise directed by a specialist”
Why: The nasal spray contains live virus.
“Live attenuated influenza vaccine, which is administered as a nasal spray, cannot be given to patients with cancer.”
Why: After contact with chickenpox or measles, a protective antibody injection or aciclovir has to be given promptly, and the history decides who needs it.
“As administration of these products should be undertaken promptly, it is important to ensure that any past history of measles and varicella disease and/or vaccination is documented, and antibody testing may be indicated.”
Why: A transplant wipes out most of the protection from earlier vaccines.
“Complete revaccination starting 6-12 months after hematopoietic stem-cell transplant should be offered in order to restore vaccine-induced immunity.”
ASCO, Journal of Clinical Oncology 2024 · Evidence quality: moderate; strength of recommendation: strong
Why: Too early and the vaccine produces little protection; there is very little evidence on the best timing.
“Adults with hematopoietic malignancies receiving CAR-T therapy directed against B-cell antigens (CD19, BCMA) should receive influenza and COVID-19 vaccine no sooner than 3 months after the completion of therapy.”
ASCO, Journal of Clinical Oncology 2024 · Evidence quality: very low; strength of recommendation: weak
Why: Vaccinated family members are less likely to bring infection home.
“It is recommended that all household members and close contacts, where feasible, be up to date on vaccinations”
ASCO, Journal of Clinical Oncology 2024 · Evidence quality: moderate; strength of recommendation: strong
Why: These vaccine viruses are not known to harm close contacts, and the family's immunity protects the patient from the real infections.
“Where household contacts of immunosuppressed individuals receive rotavirus vaccine, careful hand washing should be used to minimize the risk of transmission of vaccine virus.”
Why: Nasal vaccine virus can be shed for up to two weeks.
“Household members and others who cannot avoid contact with very severely immunocompromised patients (e.g. bone marrow transplant patients and others who require isolation) should not be offered live attenuated influenza vaccine but given appropriate alternative inactivated influenza vaccines.”
Why: Vaccinated classmates do not pass vaccine viruses on in a way that harms the child.
“Children with immunodeficiency who are attending school do not require exclusion when other children are being immunised.”
Why: Most routine childhood vaccines give a weaker, shorter response during chemotherapy and are better given or repeated afterwards.
“Live vaccines are contraindicated during and up to 6 months after end of chemotherapy.”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
For adults, ASCO 2024 is the most recent graded guideline: check vaccination status at diagnosis, vaccinate 2 to 4 weeks before treatment where possible, give non-live vaccines during or after any treatment, avoid live vaccines, and revaccinate after transplant, CAR-T and B-cell depletion on its timetable. The UK Green Book agrees on the principle but times inactivated vaccines at least two weeks before immunosuppression and sets explicit live-vaccine intervals: 6 months after immunosuppressive chemotherapy or radiotherapy, 12 months after biologics such as rituximab, 24 months after transplant, 3 months after high-dose steroids. For children, no graded international guideline was readable: the Green Book applies at every age, and the Indian Academy of Pediatrics consensus holds live vaccines until 6 months after chemotherapy, gives only inactivated influenza vaccine to all children during treatment, and prefers to give other non-live vaccines from 6 months after the end of treatment for durable immunity. Everyone agrees that household contacts should be fully vaccinated; the Green Book and ASCO both allow MMR, varicella and nasal influenza vaccine in contacts, except contacts of transplant recipients or patients in isolation.
ASCO, Journal of Clinical Oncology 2024 · Public Health England (now UK Health Security Agency) 2017 · Public Health England (now UK Health Security Agency) 2020 · Indian Academy of Pediatrics, Indian Pediatrics 2019
Where it differs: Inactivated vaccines at least two weeks before immunosuppressive treatment (ASCO: 2 to 4 weeks); live vaccines barred for fixed periods after each kind of treatment, with steroid doses that count as immunosuppressive given in milligrams and by weight for children under 20 kg.
Evidence: Ungraded national guidance from Public Health England, now the UK Health Security Agency.
Public Health England (now UK Health Security Agency) 2017 · Public Health England (now UK Health Security Agency) 2020
Where it differs: Gives only annual inactivated influenza vaccine to all children during chemotherapy, hepatitis B only to unimmunised children at risk from transfusion, and other non-live vaccines from 6 months after the end of treatment; a catch-up or re-immunisation schedule depends on what the child had before; siblings continue their vaccines but switch oral polio to the injected vaccine.
Evidence: A national consensus guideline; read here as an abstract only.
Where it differs: Although rotavirus vaccine is live, the Green Book notes that outside severe combined immunodeficiency the benefit may exceed the risk.
Evidence: Stated in a footnote to the live-vaccine list; ungraded.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Determine vaccination status and update seasonal, age- and risk-based vaccines at diagnosis | Evidence quality: moderate; strength of recommendation: strong | ASCO, Journal of Clinical Oncology 2024 |
| Vaccinate 2 to 4 weeks before treatment; non-live vaccines allowed during or after treatment | Evidence quality: moderate; strength of recommendation: strong | ASCO, Journal of Clinical Oncology 2024 |
| Full revaccination from 6 to 12 months after stem cell transplant | Evidence quality: moderate; strength of recommendation: strong | ASCO, Journal of Clinical Oncology 2024 |
| Timing after CD19 or BCMA CAR-T | Evidence quality: very low; strength of recommendation: weak | ASCO, Journal of Clinical Oncology 2024 |
| After B-cell depleting therapy, revaccinate for COVID-19 only, no sooner than 6 months after treatment “Adults who receive B-cell–depleting therapy should be revaccinated for COVID-19 only, no sooner than 6 months after completion of treatment” | Evidence quality: moderate; strength of recommendation: strong | ASCO, Journal of Clinical Oncology 2024 |
| Household members and close contacts up to date on vaccinations | Evidence quality: moderate; strength of recommendation: strong | ASCO, Journal of Clinical Oncology 2024 |
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