Additional clinical guidance can be found in recent online documents from the American Society of Hematology85 and the ASTCT86
| When can we offer COVID-19 vaccines to HCT and CAR T-cell recipients? | As early as 3 mo, the mRNA-1273 seems to be the most immunogenic, followed by BNT162b2 and Ad26.COV2.S.25 Consider administering tixagevimab and cilgavimab shortly after transplantation or cellular therapy awaiting vaccination. |
| Should we revaccinate HCT and CAR T-cell recipients, regardless of their vaccination status, before transplantation or cellular therapy? | Yes, because of the major concern for the loss of immunity after transplantation or cellular therapy. |
| When can we offer COVID-19 vaccines to nontransplant patients with hematologic malignancies? | As soon as possible, but preferably after resolution of neutropenia, if expected. |
| When can we offer COVID-19 vaccines to patients receiving IVIG? | No delay in vaccination is recommended. |
| Can patients who received mAB (either pre- or postexposure prophylaxis) receive COVID-19 vaccines? | Yes, no deferral period is recommended. However, because of concerns of decreased vaccine immunogenicity, tixagevimab and cilgavimab should be administered (≥14 d after the last vaccine inoculum) to enhance protection. |
| What is the role of serologic testing for SARS CoV-2 after COVID-19 vaccination? | Serologic testing is not recommended at this time as the commercial assays are nonstandardized, and the clinical thresholds that confer protection are not known. |
| Should COVID-19 vaccines be offered after recovery from COVID-19? | Yes, among patients who had recovered from COVID-19, ≥1 mRNA vaccine significantly decreased the risk of recurrent infection.87 |
| Should systemic anticancer treatment be delayed in the setting of COVID-19? | In most hematologic malignancies, the high efficacy of anticancer treatment favors curative standard-of-care approaches, despite the infectious risk of COVID-19. This should be considered on a case-by-case basis. |
| Should transplantation or cellular therapy be delayed in patients with COVID-19? | Defer transplantation/cellular therapy infusion for 14-21 d and until asymptomatic. In cases of high-risk underlying disease, consider deferring until 2 negative SARS-CoV-2 tests by PCR (>24 h apart); however, decisions should be made on a case-by-case basis because of prolonged viral shedding.32 |
| Should patients with hematologic malignancies undergo screening for SARS-CoV-2 infection before procedures? | All patients should undergo screening for SARS-CoV-2 infection by PCR before procedures (including admission for inpatient chemotherapy, transplantation, and cellular therapies), preferably no more than 2 to 3 d prior. |
| Should HCT donors diagnosed with COVID-19 be deferred for donation, and for how long? | Donors with SARS-CoV-2 detected in respiratory samples are considered ineligible for donation until 28 d have elapsed since symptom resolution, apart from specific considerations on a case-by-case basis (refer to the NMDP guidelines for updated guidance).32 |
| Is there any benefit to using therapeutic anticoagulation in patients with COVID-19? | No. Venous thromboembolism prophylaxis should only be used during hospitalizations when appropriate, in the absence of another indication. |
| Are antibiotics and antifungals routinely recommended for patients with COVID-19? | Routine antibiotic and antifungal treatment is not recommended in the absence of another indication.88 |
| Is routine IVIG therapy recommended for patients with COVID-19 infection? | No. Routine use of IVIG is not currently recommended in the absence of another indication. |
| When should isolation be discontinued in patients with blood cancers who have recovered symptomatically from COVID-19 with persistent viral shedding? | Immunocompromised patients, including HCT and cellular therapy recipients, may have prolonged viral shedding after contracting SARS-CoV-2. Given its sensitivity, retesting with PCR assays of nasopharyngeal samples may be positive for a long period. Therefore, retesting is not routinely recommended in immunocompromised patients who clinically recovered from COVID-19. Time-based isolation precautions, as per the CDC recommendations with the use of appropriate personnel protective equipment such as N95 respirators, are preferred in this patient population. |
| Can antispike antibody tests be used to monitor a beneficial response to SARS-CoV-2 vaccines after chemotherapy or HCT? | No, thus the need for additional booster doses. Correlation with antibody titers, mainly neutralizing antibodies, and protection from symptomatic SARS-CoV-2 infection is not well established in immunocompromised patients. |
| Does the pre-HCT recipient or donor vaccination status impact the decision to administer tixagevimab/cilgavimab? | No, tixagevimab/cilgavimab should be administered regardless of the COVID-19 vaccination status of either the recipient pre-HCT or the donor. |
| How to approach patients with prolonged COVID-19 symptoms in the presence or absence of prolonged shedding after completion of initial directed therapy for COVID-19? | If asymptomatic shedding or SARS CoV-2 infection is limited to the upper respiratory tract, it is reasonable to proceed with cancer treatment with caution. Another course of directed therapy for COVID-19 is not recommended. If there is evidence of lower respiratory tract infection, it would be prudent to delay cancer treatment, if possible, until significant improvement or complete resolution of symptoms. Treatment with a different directed therapy for COVID-19 could be considered on a case-by-case basis. |
| When can we offer COVID-19 vaccines to HCT and CAR T-cell recipients? | As early as 3 mo, the mRNA-1273 seems to be the most immunogenic, followed by BNT162b2 and Ad26.COV2.S.25 Consider administering tixagevimab and cilgavimab shortly after transplantation or cellular therapy awaiting vaccination. |
| Should we revaccinate HCT and CAR T-cell recipients, regardless of their vaccination status, before transplantation or cellular therapy? | Yes, because of the major concern for the loss of immunity after transplantation or cellular therapy. |
| When can we offer COVID-19 vaccines to nontransplant patients with hematologic malignancies? | As soon as possible, but preferably after resolution of neutropenia, if expected. |
| When can we offer COVID-19 vaccines to patients receiving IVIG? | No delay in vaccination is recommended. |
| Can patients who received mAB (either pre- or postexposure prophylaxis) receive COVID-19 vaccines? | Yes, no deferral period is recommended. However, because of concerns of decreased vaccine immunogenicity, tixagevimab and cilgavimab should be administered (≥14 d after the last vaccine inoculum) to enhance protection. |
| What is the role of serologic testing for SARS CoV-2 after COVID-19 vaccination? | Serologic testing is not recommended at this time as the commercial assays are nonstandardized, and the clinical thresholds that confer protection are not known. |
| Should COVID-19 vaccines be offered after recovery from COVID-19? | Yes, among patients who had recovered from COVID-19, ≥1 mRNA vaccine significantly decreased the risk of recurrent infection.87 |
| Should systemic anticancer treatment be delayed in the setting of COVID-19? | In most hematologic malignancies, the high efficacy of anticancer treatment favors curative standard-of-care approaches, despite the infectious risk of COVID-19. This should be considered on a case-by-case basis. |
| Should transplantation or cellular therapy be delayed in patients with COVID-19? | Defer transplantation/cellular therapy infusion for 14-21 d and until asymptomatic. In cases of high-risk underlying disease, consider deferring until 2 negative SARS-CoV-2 tests by PCR (>24 h apart); however, decisions should be made on a case-by-case basis because of prolonged viral shedding.32 |
| Should patients with hematologic malignancies undergo screening for SARS-CoV-2 infection before procedures? | All patients should undergo screening for SARS-CoV-2 infection by PCR before procedures (including admission for inpatient chemotherapy, transplantation, and cellular therapies), preferably no more than 2 to 3 d prior. |
| Should HCT donors diagnosed with COVID-19 be deferred for donation, and for how long? | Donors with SARS-CoV-2 detected in respiratory samples are considered ineligible for donation until 28 d have elapsed since symptom resolution, apart from specific considerations on a case-by-case basis (refer to the NMDP guidelines for updated guidance).32 |
| Is there any benefit to using therapeutic anticoagulation in patients with COVID-19? | No. Venous thromboembolism prophylaxis should only be used during hospitalizations when appropriate, in the absence of another indication. |
| Are antibiotics and antifungals routinely recommended for patients with COVID-19? | Routine antibiotic and antifungal treatment is not recommended in the absence of another indication.88 |
| Is routine IVIG therapy recommended for patients with COVID-19 infection? | No. Routine use of IVIG is not currently recommended in the absence of another indication. |
| When should isolation be discontinued in patients with blood cancers who have recovered symptomatically from COVID-19 with persistent viral shedding? | Immunocompromised patients, including HCT and cellular therapy recipients, may have prolonged viral shedding after contracting SARS-CoV-2. Given its sensitivity, retesting with PCR assays of nasopharyngeal samples may be positive for a long period. Therefore, retesting is not routinely recommended in immunocompromised patients who clinically recovered from COVID-19. Time-based isolation precautions, as per the CDC recommendations with the use of appropriate personnel protective equipment such as N95 respirators, are preferred in this patient population. |
| Can antispike antibody tests be used to monitor a beneficial response to SARS-CoV-2 vaccines after chemotherapy or HCT? | No, thus the need for additional booster doses. Correlation with antibody titers, mainly neutralizing antibodies, and protection from symptomatic SARS-CoV-2 infection is not well established in immunocompromised patients. |
| Does the pre-HCT recipient or donor vaccination status impact the decision to administer tixagevimab/cilgavimab? | No, tixagevimab/cilgavimab should be administered regardless of the COVID-19 vaccination status of either the recipient pre-HCT or the donor. |
| How to approach patients with prolonged COVID-19 symptoms in the presence or absence of prolonged shedding after completion of initial directed therapy for COVID-19? | If asymptomatic shedding or SARS CoV-2 infection is limited to the upper respiratory tract, it is reasonable to proceed with cancer treatment with caution. Another course of directed therapy for COVID-19 is not recommended. If there is evidence of lower respiratory tract infection, it would be prudent to delay cancer treatment, if possible, until significant improvement or complete resolution of symptoms. Treatment with a different directed therapy for COVID-19 could be considered on a case-by-case basis. |
CDC, Centers for Disease Control and Prevention; HCT, hematopoietic cell transplantation; IVIG, intravenous immune globulin; NMDP, National Marrow Donor Program.