As blood cancer patient, what do I need to know and what vaccinations should I be offered or be seeking?

Covid-19 has put vaccination front and center in everyone’s lives and demonstrated, if we didn’t already know well enough, that as blood cancer patients we are considered to be immunocompromised.

How compromised our immune systems are might vary significantly, especially for someone diagnosed in the early stages of their disease compared to someone further advanced or who is undergoing or has previously undergone treatment. But what is true for all of us is that our immune system will never be the same again, we need all of the appropriate vaccines as soon as possible to gives us the best possible protection and outcomes. Although in some cases your immune system may get less effective the longer you have the blood cancer, vaccines taken early in the disease may well go on protecting you even if you could no longer make new antibodies. Of course this will differ from person to person and on the type of blood cancer you have.

As always for individualised advice talk to your doctors.

Before covering some of the things we should be having, I want to reinforce a quick point you might already be aware of. Blood cancer patients should never have live vaccines, examples of these include the MMR (Measles, Mumps and Rubella) combined vaccine and the common Shingles vaccine Zostax (see below for more on this). Our weakened immune systems put us at greater risk from the live virus they contain.

We also need to be careful being around others who have had live vaccines, most especially children who have had the flu vaccine which comes in the form of a nasal spray since since it is quite likely they could be breathing out live flu virus.

So, onto considering what we should be having. The specific vaccinations you might need to seek will depend on what the normal national vaccination procedure is in your country and what you’ve already had.

Flu (Influenza)
One of the easiest ones to tick of the list is the standard annual flu vaccination. This is an important vaccine that is actually useful even for those who aren’t immunocompromised, but is even more important for us. It contains a deactivated influenza virus, or more usually a combination of several strains of influenza based on which strains the experts think are going to be most prevalent. You should have the available flu vaccine every year, although if you are having, just starting, or have just finished treatment you should consult your doctor first. It is also vital to have anyone who lives with you (and ideally anyone who works closely with you) vaccinated as well. Children may sometimes be given the injection rather than the nose spray, the nasal spray is a live virus however and you may need to avoid or be very careful around children who have just received this.
UK Green Book information on this vaccination can be found at the following link, however this is one that basically everyone no matter their immune status should be having.

Green Book Chapter 19

Pneumonia
With some blood cancers, especially chronic types such as CLL, the most common cause of death is actually an infection and by far the most common infection that’s responsible is pneumonia. There are two main pneumonia vaccinations available, Prevnar 13 (aka PCV 13) and Pneumovax 23 (aka PPV 23). Unfortunately those with compromised immune systems may not have much of a response to PPV 23, but you should get it anyway. Importantly you should ensure you get them in the correct order, Prevnar 13 first and Pneumovax 23 at least 2 months later. You can read the guidance on this from the relevant national body in your country, in the UK this is the Green Book (Immunisation Against Infectious Disease) Chapter 25 Page 8

In the USA the guidance is from the CDC and can be found here however they both say much the same thing.

Coronavirus(COVID19)
Unless you’ve been living under a rock you can’t have missed the impact of the Covid-19 pandemic on the world. This virus has been shown to have the potential to be fatal even in otherwise healthy people so for those of us with compromised immune systems it is even more of a concern. A number of safe and generally effective vaccines have been developed, and it’s extremely important that those of us with blood cancer have them. Hopefully by the time you’re reading this you’ve already had at least one dose, but if not you should contact your doctor or relevant health authorities as soon as possible and arrange yours.

Unfortunately early evidence so far is showing that many blood cancer patients are having little to no response to the current vaccines, but this is far from conclusive and any protection it might give you is better than none.
See some more detail on this in articles Adrian has written here and here.

Again UK Green Book information on this vaccination can be found at the following link, but this is another one that everyone should be getting to protect both themselves and the rest of the world. Note that there have been some concerns about rare blood clotting issues caused by a couple of the vaccines however the risk of this is very very low and there are other vaccines available in any case so please do make sure you get some form of Covid vaccine.

Green Book Chapter 14

In the UK it is now recommended that children between the age of 12 and 18 are offered the COVID19 vaccine if they live with immune compromised people including blood cancer patients.

Hib(Haemophilus influenzae type B)/Meningitis
This section actually includes a several vaccines. Firstly the Hib/MenC vaccine which is a combined vaccine for these two conditions. Haemophilus Influenzae Type B is a bacteria which can cause severe pneumonia and meningitis, while this is almost exclusively in children under 5 and is now a standard vaccination for children in the UK, it is a risk for us because of our immune compromised state and was only introduced as a routine vaccination for children fairly relatively recently so you’re unlikely to have had it. It is combined with the vaccine for Meningitis C, Meningitis is a bacterial infection of the Meningococcal bacteria the bacteria can also cause septicemia (blood poisoning), the different strains are categorised into groups and this vaccine protects against group C of these bacteria.

It is worth noting with this vaccine that the UK Green Book (Chapter 16 Page 8) states it should be given with a dose of PPV23 therefore can, and possibly should, be arranged to be done at the same time as this.

Another vaccine we can get is the MenACWY meningitis vaccine, which as you might infer from the paragraph above protects against groups A,C,W and Y of the Meningococcal bacteria. The previously linked Green Book chapter on the Hib/MenC vaccine advises that this vaccine should be given one month after the Hib/MenC vaccine.

Green Book chapter 16

Shingles (Herpes Zoster Virus)
For sometime there had only been one vaccine for Shingles, which is a live vaccine manufactured under the brand Zostavax. Unfortunately as this is a live vaccine is not suitable for the immune compromised such as blood cancer patients. More recently a new vaccine called Shingrix which is a non-live vaccine (produced synthetically in a lab using the zoster virus DNA).

In the UK the vaccine is unfortunately not yet available via the NHS, though it can obtained privately via certain travel clinics who are able to import it. It consists of two doses at a cost of approximately £500.
The vaccine is available in the USA, and is recommend by the CDC for the prevention of Shingles.
See the CDC recommendations for the Shingrix vaccine here

CDC Shingrex Guidelines

As a general philosophy getting all the non-live vaccines you can, as soon as you can, is probably the best approach especially if you have a chronic blood cancer such as CLL. If you’re not currently in treatment then your immune system isn’t going to be any better than it is right now so getting everything you can as soon as you can puts you at the best chance of getting the best response you can to each vaccine. This approach is especially true if you are considering travelling, if there non-live vaccines required or recommend for any countries you intend visit in the next few years get the vaccines sooner rather than later even if the trip isn’t fully planned out yet.

Links for further information:

• The CLL Society has some helpful information on vaccinations those with CLL should seek.
• The UK Green Book (aka Immunisation Against Infectious Disease)
• The USA CDC guidance on vaccinations for diseases and their specific page on vaccines for the immunocompromised, which lists pneumonia, meningitis and Hib
• The Canadian Public Health authority provides some extensive information on vaccines, and has a rather nice chart showing which vaccines are available or recommended based on specific types of immune deficiency.
  
  
  It would also be worth a read of Adrian’s post “Just how bad is my immune system” for some consideration of how and why the immune systems of blood cancer patients are compromised and to what extent.

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