Vaccinations

Infections are the biggest killers of CLL patients, so vaccinations are very important. If we have them early in our disease, we are more likely to be able to produce antibodies and so they are more likely to be effective. The following are those commonly recommended:

Annual flu vaccine.

Have this as early as possible. It’s usually available from mid September each year. It’s also important that our nearest and dearest have the jab. They’ll get better responses than us and if they don’t get flu, they won’t give it to us. In the UK, partners and carers are entitled to have flu jabs on the NHS.

NOTE that children who are vaccinated are given ‘live’ attenuated virus via a nasal spray and that these children shed the virus for a few days afterwards, perhaps up to a week.

Public Health England have stated that this virus is less able to spread from person to person and is shed at levels unlikely to cause infection. However, CLL patients can be severely immunocompromised and it may be prudent to avoid children who have been vaccinated for the period during which they are shedding the virus.

TWO Pneumonia vaccines –

First Prevnar 13 (PCV 13), then at least 2 months later

Pneumovax 23 (PPV 23 - also known as PPSV23).

 

Although “The Green Book” (official UK source for vaccination advice) recommends a gap of at least two months between these vaccs, some doctors prefer to wait longer.

Prevnar13 has only recently been put on the recommended list for CLL folk, and some GPs are not aware of this as it used to be only for infants.

If you're offered a Pneumonia vaccination for the first time, make sure it is Prevnar 13 (PCV13).

If you’ve already had Pneumovax (without having had Prevnar),  you can still have both the vaccinations BUT when they're given in this other order a  longer gap is recommended, usually 12 months, between the vaccinations.

 

Note - Sadly many CLL folk get very little response to Pneumovax 23 (a polysaccharide vaccine) but most people have a better response to Prevnar (a conjugate vaccine).

Haemophilus influenzae type B (Hib).

HiB is a very nasty bug that can cause many infections including pneumonia and meningitis.

The vaccine often comes as Hib/MenC, which is a combination of Hib and Meningococcal C vaccines.

 

Meningococcol C

As mentioned above, Meningococcal C vaccine is often combined with the Hib vaccine (Hib/MenC). Vaccines for other strains of meningitis may also be recommended, such as Meningitis B and Meningitis ACWY.

 

Consider boosters for Tetanus/Diptheria/Pertussis (whooping cough), if it's been over 10 years since you've had them.

Ask your doctor about possible Hepatitis vaccines.

 

You might benefit from various boosters eg Pneumovax (PPV23) is recommended every 5 years. You will need to ask for this as normally only given once. Some doctors like to test for antibody levels before another vaccination, to see if boosters would be helpful. 

 

LIVE” VACCINES SHOULD NEVER be given to CLL patients.

Unfortunately, the present shingles vaccine is ‘live’ so NOT for us, but a new “non-live” shingles vaccine is in the pipeline that might be available in the next year or so). We should also be aware that we may need to avoid people who’ve had live vaccines and may be shedding the virus.

Check with your haematologist, in case there are other reasons why you shouldn't have vaccines. eg. when certain treatments are imminent, taking place or during the 6 months afterwards.

Although we probably won’t get the best protection from vaccinations because our immune systems don't work so well, most CLL specialists still recommend we get vaccinated. We sometimes respond much better than expected, even at advanced stages in our disease.

In short, ask your doctors about vaccinations for

  1. Prevnar 13, then Pneumovax 23 at least two months later (for pneumonia)

  2. Annual flu jabs (for you AND those close to you)

  3. HiB/MenC (for Haemophilus Influenzae typeB and Meningococcal C).

  4. Ask about other strains of meningococcal vaccines. 

  5. Check if you need boosters for tetanus, diptheria, whooping cough

  6.  

Vaccinations should be avoided, if possible, 2 weeks prior to, during or up to 6 months after chemo-immunotherapy. UK CLL Clinical guidelines  

 

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There are other vaccines that are permissible for CLL folk, but we don't usually need all of them unless we face a particular risk of those infections.

A full list is given here. It starts by listing vaccines that should be avoided, but read down a bit to find the "Permissable" ones. 

Remember the Warning:

CLL patients should not be given live vaccines and should avoid contact with those who have been given live vaccines for about 10 days after the vaccination was given. 

The shingles and Nasal flu and oral polio vaccines are all live. 

References:

 

For the UK, the recommendation for Pneumonia vaccinations is in “The Green Book”, page 304, third paragraph. This states:

"Children aged 10 years onwards and adults diagnosed with other at-risk conditions ….. Those in this age group who are severely immunocompromised* should be offered a single dose of PCV13 followed by PPV23 at least two months later (irrespective of their previous pneumococcal vaccinations)…

*including bone marrow transplant patients, patients with acute and chronic leukaemia, multiple myeloma or genetic disorders affecting the immune system.” (Relevant bits put in bold - Ed)

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/263318/Green-Book-Chapter-25-v5_2.pdf

 

Another UK reference re pneumococcal vaccines is: http://www.nhs.uk/conditions/vaccinations/pages/when-is-pneumococcal-vaccine-needed.aspx “…anyone with leukaemia; multiple myeloma; genetic disorders affecting the immune system or after a bone marrow transplant) usually have a single dose of PCV followed by PPV.”

 

This Irish site gives more detailed information for Pneumonia vaccinations, and also mentions some other vaccinations to be considered. https://www.hse.ie/ensg/health/immunisation/hcpinfo/guidelines/chapter3.pdf

 

The following link is to the USA (Centre for Disease Control), but is nice and clear, covering many different vaccinations. http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule-easy-read.pdf . Scroll down to the second chart and look at the line for "weakened immune system".

 

This is another US site that gives more details about timings of pneumococcal vaccinations.

https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf

 

Shedding 

Anyone who has had a live vaccine will shed live vaccine strain virus into their body fluids in exactly the same way with a viral infection. 

So anyone given a live vaccine can pass on the virus to other people they come in contact with. 

The nasal flu vaccine given to children in the UK is a live virus so anyone with CLL should avoid close contact for about 10 days after the vacination was given.

Be aware that babies and children in the household should receive inactivated (injection form) of polio vaccine rather than the oral (live virus) vaccine.

Be aware the children's nasal spray flu vaccination is a live vaccine. Consult the child's doctor (paediatrician).

If you have had a stem cell transplant, then your new immune system will need to ‘re learn to recognise’ all infections. 

Your own immune status must be determined by your own doctors. There are no rules that say that a new CLL patient does not have a damaged immune system or that at 6 months after chemotherapy your immune system will have recovered. Unfortunately, there are many people who have damaged immune systems many years after chemotherapy. 

Further Reading 

Read full 2014 introduction to CLL by Prof Fegan  MB, MD, FRCP, FRCPath

Studies evidence CLL patients do not respond to polysaccharide vaccine. Earlier writing on this from Prof Hamblin Vaccination against pneumonia also Infections by Professor T Hamblin

2012 UK guidelines on the diagnosis, investigation and management of chronic lymphocytic leukaemia 

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