Cancer patients are one of the susceptible populations at risk of infections due to intensive and immune response-altering treatments. Among the infections, Streptococcus pneumoniae-related infections have a significant impact on cancer patients. These infections can be seen as mild or invasive type which varies in severity according to the type of cancer. Invasive pneumococcal disease is a serious infection that increases morbidity and mortality in cancer patients. Ensuring the integrity of patients' immunity is essential in order to maintain safe and effective cancer treatment processes. International guidelines and health authorities recommend that cancer patients should receive pneumococcal vaccines against pneumococcal diseases. The administration of vaccines in cancer patients is more complicated than in any other patient groups due to ongoing immunosuppressive treatments, which results in not achieved desired rates in pneumococcal vaccination. The vaccination process requires comprehensive assessment of the factors directly related with cancer, such as cancer type/diagnosis, cancer stage, type of treatment and scheduled treatment along with other patient-related factors. Sustainability of immunization in adult population can be achieved by implementation of vaccination programs, although logistics, economic, social, and epidemiological factors hinder its implementation. In order to increase the vaccination rates, health professionals should work in cooperation with the patient. Pharmacists, as healthcare professionals, have contributed to increased vaccination rates in cancer patients by providing vaccine consultancy and as vaccine practitioners in some countries. This review focuses on pneumococcal infections observed in cancer patients, vaccination process, and pharmacist's role in vaccination.
Keywords: Cancer survivors; Streptococcus pneumoniae infections; pharmacist; vaccination
Kanser hastaları, almış oldukları yoğun ve bağışıklık yanıtını değiştiren tedaviler nedeniyle enfeksiyon riski altındaki duyarlı popülasyonlardan biridir. Bu enfeksiyonlar arasında Streptococcus pneumoniae enfeksiyonları kanser hastalarında önemli bir etkiye sahiptir. Bu enfeksiyonlar, kanserin tipine göre şiddeti değişen hafif veya invaziv tipte görülebilmektedir. İnvaziv pnömokok hastalığı, kanser hastalarında morbidite ve mortaliteyi artıran ciddi bir enfeksiyondur. Güvenli ve etkili kanser tedavi süreçlerini sürdürmek için hastaların bağışıklığının bütünlüğünü sağlamak çok önemlidir. Uluslararası kılavuzlar ve sağlık otoriteleri, kanser hastalarının pnömokok hastalıklarına karşı pnömokok aşısı ile aşılanmalarını önermektedir. Kanser hastalarında aşıların uygulanması, devam eden immünsupresif tedaviler nedeniyle diğer hasta gruplarına göre daha karmaşıktır ve bu da pnömokok aşısıyla aşılamada istenilen oranlara ulaşılamaması ile sonuçlanmaktadır. Aşılama süreci, kanser türü, kanser tanısı, kanser evresi, tedavi türü ve planlanan tedavi süreci gibi kanserle doğrudan ilişkili faktörlerin ve hastayla ilgili diğer faktörlerin kapsamlı bir değerlendirmesini gerektirmektedir. Lojistik, ekonomik, sosyal ve epidemiyolojik faktörler aşı uygulanması önündeki bariyerler olsa da erişkin popülasyonda bağışıklamanın sürdürülebilirliği, aşılama programlarının uygulanmasıyla sağlanabilmektedir. Aşılanma oranlarının artması için sağlık profesyonellerinin hasta ile iş birliği içerisinde çalışması gerekmektedir. Eczacılar, sağlık profesyonelleri olarak, aşı danışmanlığı yaparak ve bazı ülkelerde aşı uygulayıcısı olarak kanser hastalarında aşı oranlarının artmasına katkıda bulunmaktadır. Bu derleme, kanser hastalarında gözlenen pnömokok enfeksiyonları, aşılama süreci ve eczacının aşılamadaki rolüne odaklanmaktadır.
Anahtar Kelimeler: Kanser survivorları; Streptococcus pneumoniae enfeksiyonları; eczacılar; aşılama
- Cancer World Health Organization [Internet]. © 2021 WHO. [Cited: July 24, 2021]. Cancer. Available from: [Link]
- National Institutes of Health (US); Biological Sciences Curriculum Study. NIH Curriculum Supplement Series. Bethesda (MD): National Institutes of Health (US). Understanding Cancer [Internet]. Cited: Jun 29, 2021. Available from: [Link]
- Feitelson MA, Arzumanyan A, Kulathinal RJ, Blain SW, Holcombe RF, Mahajna J, et al. Sustained proliferation in cancer: mechanisms and novel therapeutic targets. Semin Cancer Biol. 2015;35 Suppl(Suppl):S25-S54. [Crossref] [PubMed] [PMC]
- Cooper GM. The Cell: A Molecular Approach. 2nd ed. Massachusetts: Sinauer Associates; 2000.
- World Health Organization [Internet]. © 2021 WHO. [Cited: Agust 12, 2021]. Cancer 2018. Available from: [Link]
- World Health Organization. Global Cancer Observatory-Turkey 2020. Cited: Agust 12, 2021. Available from: [Link]
- National Cancer Control Indicators [Internet]. © 2021 - CANCER AUSTRALIA. [Cited: Agust 15, 2021]. Relative Survival Rates-5 year relative survival 2020. Available from: [Link]
- Blimark C, Holmberg E, Mellqvist UH, Landgren O, Björkholm M, Hultcrantz M, et al. Multiple myeloma and infections: a population-based study on 9253 multiple myeloma patients. Haematologica. 2015;100(1):107-13. [Crossref] [PubMed] [PMC]
- Pagano L, Caira M, Rossi G, Tumbarello M, Fanci R, Garzia MG, et al; Hema e-Chart Group, Italy. A prospective survey of febrile events in hematological malignancies. Ann Hematol. 2012;91(5):767-74. [Crossref] [PubMed]
- Marin M, Gudiol C, Ardanuy C, Garcia-Vidal C, Calvo M, Arnan M, et al. Bloodstream infections in neutropenic patients with cancer: differences between patients with haematological malignancies and solid tumours. J Infect. 2014;69(5):417-23. [Crossref] [PubMed]
- Lustberg MB. Management of neutropenia in cancer patients. Clin Adv Hematol Oncol. 2012;10(12):825-6. [PubMed] [PMC]
- Wong JL, Evans SE. Bacterial pneumonia in patients with cancer: novel risk factors and management. Clin Chest Med. 2017;38(2):263-77. [Crossref] [PubMed] [PMC]
- Ocal N, Bilgiç H, Ucar E. Defence system of respiratory tract and clearence of inhalation agents. J Clin Anal Med. 2015;6:246-9.
- Carolia MN, Karen JV, Adachi JA. Bacterial colonization and host immunity. In: Safdar A, ed. Principles and Practice of Cancer Infectious Diseaes. 1st ed. New York: Humana Press; 2011.
- Zarco-Márquez S, Volkow-Fernández P, Velázquez-Acosta C, Echániz-Avilés G, Carnalla-Barajas MN, Soto-Noguerón A, et al. Invasive and complicated pneumococcal infection in patients with cancer. Rev Invest Clin. 2016;68(5):221-8. [PubMed]
- Rolston KV. Infections in cancer patients with solid tumors: a review. Infect Dis Ther. 2017;6(1):69-83. [Crossref] [PubMed] [PMC]
- Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1994;271(20):1598-601. [Crossref] [PubMed]
- Henriques-Normark B, Tuomanen EI. The pneumococcus: epidemiology, microbiology, and pathogenesis. Cold Spring Harb Perspect Med. 2013;3(7):a010215. [Crossref] [PubMed] [PMC]
- Loughran AJ, Orihuela CJ, Tuomanen EI. Streptococcus pneumoniae: invasion and inflammation. Microbiol Spectr. 2019;7(2):10.1128/microbiolspec.GPP3-0004-2018. [PubMed] [PMC]
- Bogaert D, De Groot R, Hermans PW. Streptococcus pneumoniae colonisation: the key to pneumococcal disease. Lancet Infect Dis. 2004;4(3):144-54. [Crossref] [PubMed]
- Almeida ST, Pedro T, Paulo AC, de Lencastre H, Sá-Leão R. Re-evaluation of Streptococcus pneumoniae carriage in Portuguese elderly by qPCR increases carriage estimates and unveils an expanded pool of serotypes. Sci Rep. 2020;10(1):8373. [Crossref] [PubMed] [PMC]
- Weiser JN, Ferreira DM, Paton JC. Streptococcus pneumoniae: transmission, colonization and invasion. Nat Rev Microbiol. 2018;16(6):355-67. [Crossref] [PubMed] [PMC]
- World Health Organization [Internet]. [Cited: Agust 25, 2021]. Pneumococcal Disease 2015. Available from: [Link]
- van Werkhoven CH, Huijts SM. Vaccines to prevent pneumococcal community-acquired pneumonia. Clin Chest Med. 2018;39(4):733-52. [Crossref] [PubMed]
- Garcia Garrido HM, Knol MJ, Heijmans J, van Sorge NM, Sanders EAM, Klümpen HJ, et al. Invasive pneumococcal disease among adults with hematological and solid organ malignancies: a population-based cohort study. Int J Infect Dis. 2021;106:237-45. [Crossref] [PubMed]
- Jung J, Moon SM, Jang HC, Kang CI, Jun JB, Cho YK, et al. Incidence and risk factors of postoperative pneumonia following cancer surgery in adult patients with selected solid cancer: results of "Cancer POP" study. Cancer Med. 2018;7(1):261-9. [Crossref] [PubMed] [PMC]
- Johansson N, Kalin M, Hedlund J. Clinical impact of combined viral and bacterial infection in patients with community-acquired pneumonia. Scand J Infect Dis. 2011;43(8):609-15. [Crossref] [PubMed]
- Dandachi D, Rodriguez-Barradas MC. Viral pneumonia: etiologies and treatment. J Investig Med. 2018;66(6):957-65. [Crossref] [PubMed]
- Pletz MW, Rohde GG, Welte T, Kolditz M, Ott S. Advances in the prevention, management, and treatment of community-acquired pneumonia. F1000Res. 2016;5:F1000 Faculty Rev-300. [Crossref] [PubMed] [PMC]
- Daniels CC, Rogers PD, Shelton CM. A review of pneumococcal vaccines: current polysaccharide vaccine recommendations and future protein antigens. J Pediatr Pharmacol Ther. 2016;21(1):27-35. [Crossref] [PubMed] [PMC]
- Berical AC, Harris D, Dela Cruz CS, Possick JD. Pneumococcal vaccination strategies. An update and perspective. Ann Am Thorac Soc. 2016;13(6):933-44. [Crossref] [PubMed] [PMC]
- Türkiye Enfeksiyon Hastalıkları ve Klinik Mikrobiyoloji Uzmanlık Derneği. Erişkin Bağışıklama Rehberi; 2016. [Link]
- Principi N, Esposito S. Prevention of community-acquired pneumonia with available pneumococcal vaccines. Int J Mol Sci. 2016;18(1):30. [Crossref] [PubMed] [PMC]
- Papadatou I, Tzovara I, Licciardi PV. The role of serotype-specific immunological memory in pneumococcal vaccination: current knowledge and future prospects. Vaccines (Basel). 2019;7(1):13. [Crossref] [PubMed] [PMC]
- Robin C, Beckerich F, Cordonnier C. Immunization in cancer patients: where we stand. Pharmacol Res. 2015;92:23-30. [Crossref] [PubMed]
- Chang A, Ellingson MK, Flowers CR, Bednarczyk RA. Influenza vaccination rates among patients with a history of cancer: analysis of the national health interview survey. Open Forum Infect Dis. 2021;8(7):ofab198. [Crossref] [PubMed] [PMC]
- Tsigrelis C, Ljungman P. Vaccinations in patients with hematological malignancies. Blood Rev. 2016;30(2):139-47. [Crossref] [PubMed]
- Rubin LG, Levin MJ, Ljungman P, Davies EG, Avery R, Tomblyn M, et al; Infectious Diseases Society of America. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):e44-100. [Crossref] [PubMed] 
- Kang DH, Weaver MT, Park NJ, Smith B, McArdle T, Carpenter J. Significant impairment in immune recovery after cancer treatment. Nurs Res. 2009;58(2):105-14. [Crossref] [PubMed] [PMC]
- Guzek A, Berghoff AS, Jasinska J, Garner-Spitzer E, Wagner A, Stiasny K, et al. Reduced seroprevalence against vaccine preventable diseases (VPDs) in adult patients with cancer: necessity of routine vaccination as part of the therapeutic concept. Ann Oncol. 2020;31(2):319-21. [Crossref] [PubMed]
- Centers for Disease Control and Prevention. General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP) 2021. Cited: September 13, 2021. Available from: [Link]
- Centers for Disease Control and Prevention [Internet]. [Cited: September 19, 2022]. Recommended Adult Immunization Schedule for ages 19 years or older 2021. Available from: [Link]
- Wehbi NK, Wani RJ, Klepser DG, Murry J, Khan AS. Impact of implementing a technology platform in community pharmacies to increase adult immunizations rates. Vaccine. 2019;37(1):56-60. [Crossref] [PubMed]
- Isenor JE, Edwards NT, Alia TA, Slayter KL, MacDougall DM, McNeil SA, et al. Impact of pharmacists as immunizers on vaccination rates: a systematic review and meta-analysis. Vaccine. 2016;34(47):5708-23. [Crossref] [PubMed]
- Hattingh HL, Sim TF, Parsons R, Czarniak P, Vickery A, Ayadurai S. Evaluation of the first pharmacist-administered vaccinations in Western Australia: a mixed-methods study. BMJ Open. 2016;6(9):e011948. [Crossref] [PubMed] [PMC]
- Poudel A, Lau ETL, Deldot M, Campbell C, Waite NM, Nissen LM. Pharmacist role in vaccination: Evidence and challenges. Vaccine. 2019;37(40):5939-45. [Crossref] [PubMed]
- International Pharmaceutical Federation (FIP). The FIP vaccination reference guide.Knowledge and skills to support professional development and inform pharmacy education in vaccination 2022. Cited: September 19, 2022. Available from: [Link]
- Yemeke TT, McMillan S, Marciniak MW, Ozawa S. A systematic review of the role of pharmacists in vaccination services in low-and middle-income countries. Res Social Adm Pharm. 2021;17(2):300-6. [Crossref] [PubMed]
- Cassidy C, Langley J, Steenbeek A, Taylor B, Kennie-Kaulbach N, Grantmyre H, et al. A Behavioral analysis of nurses' and pharmacists' role in addressing vaccine hesitancy: scoping review. Hum Vaccin Immunother. 2021;17(11):4487-504. [Crossref] [PubMed] [PMC]
- Sitte J, Frentiu E, Baumann C, Rousseau H, May T, Bronowicki JP, et al. Vaccination for influenza and pneumococcus in patients with gastrointestinal cancer or inflammatory bowel disease: a prospective cohort study of methods for improving coverage. Aliment Pharmacol Ther. 2019;49(1):84-90. [Crossref] [PubMed]
- Toleman MS, Herbert K, McCarthy N, Church DN. Vaccination of chemotherapy patients--effect of guideline implementation. Support Care Cancer. 2016;24(5):2317-21. [Crossref] [PubMed]
- Delacruz W, Terrazzino S, Osswald M, Payne C, Haney B. Implementing a multidisciplinary approach to enhance compliance with guideline-recommended prechemotherapy pneumococcal vaccination in a military-based medical oncology practice. J Oncol Pract. 2017;13(11):e966-71. [Crossref] [PubMed]
- McGinnis JM, Jones R, Hillis C, Kokus H, Thomas H, Thomas J, et al. A pneumococcal pneumonia and influenza vaccination quality improvement program for women receiving chemotherapy for gynecologic cancers at a major tertiary cancer Centre. Gynecol Oncol. 2021;161(1):236-43. [Crossref] [PubMed]
- Church EC, Banks R, Wilson B, Arfons L, Perez F, Jump R. Improving pneumococcal vaccine uptake in veterans with chronic lymphocytic leukemia through a virtual clinic. Curr Oncol. 2018;25(1):e95-8. [Crossref] [PubMed] [PMC]
- Goldsworthy J, Salvati L, Tomlin CR, Jenkins T, Jameson A, Dumkow LE. Impact of a pharmacist-led pneumococcal vaccination outreach program in a primary care setting. Journal of American Collage of Clinical Pharmacy. 2022;5:302-9. [Crossref]
- Sheer RL, Nau DP, Dorich N, Boyer AD, Pickering M, Campbell PJ, et al. Medicare advantage-pharmacy partnership improves influenza and pneumococcal vaccination rates. Am J Manag Care. 2021;27(10):425-31. [Crossref] [PubMed]
- Abu-Rish EY, Barakat NA. The impact of pharmacist-led educational intervention on pneumococcal vaccine awareness and acceptance among elderly in Jordan. Hum Vaccin Immunother. 2021;17(4):1181-9. [Crossref] [PubMed] [PMC]
- Caffrey AR, DeAngelis JM, Ward KE, Orr KK, Morrill HJ, Gosciminski M, et al; Rhode Island Pharmacy Pneumococcal Vaccination Education Group. A pharmacist-driven academic detailing program to increase adult pneumococcal vaccination. J Am Pharm Assoc (2003). 2018;58(3):303-10. [Crossref] [PubMed]
- Towards one FIP Working in trust and solidarity. International Pharmaceutical Federation Annual Report 2020. [Link]
- The International Pharmaceutical Federation (FIP) [Internet]. © Copyright International Pharmaceutical Federation 2022. [Cited: September 19, 2022]. Transforming Vaccination Globally, Regionally and Nationally 2021. Available from: [Link]
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