What Are the Recommended Vaccination Guidelines for Myeloma Patients?
This publication was approved and written in close collaboration with Dr. Heinz Ludwig.
Dr. Heinz Ludwig is director of the Wilhelminen Cancer Research Institute in Vienna, Austria. Dr. Ludwig is a featured expert in our health equity-focused Pro Hub that lists inclusive global healthcare professionals committed to advancing inclusive research and providing the highest quality care to all patients.
These articles are written by Diverse Health Hub to summarize complex medical research in order to facilitate deeper understanding. Diverse Health Hub publications are not intended to persuade its readers. We present information to create in-depth conversations that encourage patients to critically think and decide for themselves.
Studies centering on vaccinations for myeloma patients have been limited in the past due to their low participation rate in trials coupled with negligent measures of patient outcomes. This month, we connected with hematologist and multiple myeloma expert Dr. Heinz Ludwig about a compilation of myeloma research studies he was involved in called Recommendation for Vaccination for Multiple Myeloma: A Consensus of the European Myeloma Network. Dr. Ludwig is Director of the Wilhelminen Cancer Research Institute in Vienna. He is dedicated to improving the quality of cancer care by promoting medical training and research, empowering patients with information about myeloma, and informing the wider public about patient needs. The research we review looks at vaccination recommendations of multiple myeloma patients by a group of the European Myeloma Network.
In reviewing this research study, we examine:
risk of infection for myeloma patients and possible prevention with vaccines
available vaccines and recommendations for clinical practice
benefits and limitations of vaccines
Risk of Infection for Myeloma Patients
For multiple myeloma patients and loved ones wondering about viruses, bacterial infections, and other diseases, vaccinations are vital due to their compromised immune system. According to the European Myeloma Network, vaccinations can help prevent the flu, pneumonia, novel coronavirus, chickenpox, bacterial infections, as well as other viruses. Vaccinations are also especially important for myeloma patients who plan to have autologous and allogeneic stem cell transplants, which are known to reduce antibody levels significantly.
Infections are the second leading cause of death among multiple myeloma patients after the disease itself, thus leading to the recommendations for vaccinations. Even those in the early stage of monoclonal gammopathy of undetermined significance (MGUS) have an increased risk of infection. The risk continues to go up in those starting myeloma therapy. Risk for viral infections were shown to be 10 times higher in myeloma patients and seven times higher for bacterial infections in one population-based study. Lowered antibody production and T-cell function from treatment put myeloma patients at increased risk. Along with a compromised immune system, myeloma therapy often leads to cytopenia — a reduction in the number of mature blood cells in a patient. These two factors together may contribute to the reduced function of mucus membranes that protect the patient from infections.
There are specific recommendations around the timing of vaccinations for myeloma patients in relation to their treatments. These conditions are outlined in the next section.
Available Vaccines and Recommendations for Myeloma Patients
Research conducted by the European Myeloma Network created detailed guidelines for vaccine recommendations in multiple myeloma patients.
Influenza
For myeloma patients without documented immune response, the flu vaccination is shown in the research finding to increase protection enough to warrant vaccination in myeloma patients. Flu vaccination is recommended in two doses to be given 30 days apart.
Varicella Zoster Virus (VZV)
One area of myeloma research looked specifically at the reactivation of varicella zoster virus (VZV). The research showed an increased risk of varicella zoster virus reactivation in myeloma patients who had received treatment with proteasome inhibitors, daratumumab (Darzalex), high-dose melphalan (Alkeran) followed up with autologous stem cell transplant, and high doses of glucocorticosteroids. Although considered to be safe, use of varicella zoster virus vaccines that contain live virus are not recommended for myeloma patients. Instead, the research recommended vaccination with recombinant varicella zoster virus glycoprotein E vaccine, which showed an extremely low risk of VZV reactivation.
Two doses of recombinant varicella zoster are recommended to be given 2 to 6 months apart. The use of acyclovir or valaciclovir was also recommended in combination with the recombinant vaccine for additional protection against infection.
Hepatitis A
For hepatitis A vaccination, myeloma patients without immunity to the virus are advised to get vaccinated if planning to travel to the regions of Southeast Asia, Africa, Central America, South America, and the Mediterranean. Two doses of inactivated hepatitis A vaccination are recommended to be given at least 6 months apart. An alternate option of receiving intravenous immunoglobulin as a prevention measure can be used for myeloma patients with limited exposure to the virus.
Hepatitis B
Screening for hepatitis B HBs-Ag and anti-HBc- antibodies should be performed for myeloma patients planning to be treated with any of the following:
high-dose dexamethasone
immunomodulatory drugs
monoclonal antibodies
proteasome inhibitors
stem cell transplantation
Depending on results, the research advised specific courses of vaccination in some cases:
For myeloma patients who have either positive hepatitis B DNA or positive test results with HBs-Ag antibodies, antiviral therapy of entecavir or tenofovir is recommended for those patients in addition to anti-myeloma treatments with a preference for treating until anti-myeloma treatment is complete.
For patients who show no evidence of hepatitis B infection from their test results, hepatitis B vaccination is only recommended for those who plan to travel to areas known to have regular occurrence of hepatitis B or if they have a sexual partner who has hepatitis B.
If a myeloma patient tests positive for anti-HBc antibodies but negative for HBs-Ag antibodies, a test for hepatitis B DNA should be done to determine the next course of action.
Hepatitis C
In the case of hepatitis C, a vaccine has not yet been developed. Myeloma patients who plan to start immunosuppressive therapy should be screened for hepatitis C RNA before starting treatment, if possible. The research recommends treatment with antiviral medications before myeloma treatment in those patients who test positive for hepatitis C RNA.
Measles, Mumps, and Rubella (MMR)
Though immunity against measles, mumps, and rubella usually lasts a lifetime after vaccination, revaccination is recommended for myeloma patients after allogeneic stem cell transplantation, According to the research, revaccination with one to two doses is recommended more than 24 months following the allogeneic transplant. The dosage can be determined after the antibody levels have been determined from antibody testing.
Pneumococci
For the prevention of the bacterial infections of pneumonia, sepsis, and bacterial meningitis, the research recommends that myeloma patients should receive the 13-valent vaccine if they’ve never received it. This vaccination should be followed by the 23-valent vaccine two months or longer after the 13-valent vaccine.
Haemophilus Influenzae
The haemophilus influenzae bacteria is frequently found in the nasal passages and can lead to sinus infections and then cause pneumonia, sepsis, and meningitis. Although the data on efficacy of the vaccination for myeloma patients is limited, the research still recommends vaccination for myeloma patients.
Meningococci
Myeloma patients are at higher risk of meningococcal disease due to a variety of factors including low immunoglobulin levels, other deficiencies, and potential reduced spleen function. The research recommends vaccination with the tetravalent conjugated vaccine for all myeloma patients, especially those who are known to have reduced spleen function, other deficiencies, as well as patients who’ve had hematopoietic stem cell transplants.
Diphtheria, Pertussis, Tetanus, and Polio (DTaP)
Although there is limited information on immunity for diphtheria, pertussis, tetanus, and polio, the research paper recommends DTaP vaccination for myeloma patients following allogeneic transplants.
Recommendations for Vaccination Schedules for Myeloma Patients After Autologous or Allogeneic HCT
With advances in vaccine development, there are many available vaccines — some inactivated vaccines and some live vaccines — that are recommended for myeloma patients following autologous or allogeneic hematopoietic cell transplantation (HCT).
Recommended Inactivated Vaccines:
diphtheria/tetanus/acellular pertussis (DTaP) - 3 doses timed 6 to 12 months following allogeneic or autologous HCT
Hepatitis A (Hep A) - 2 doses 6 to 12 months following allogeneic or autologous HCT
Hepatitis B (Hep B) - 3 doses 6 to 12 months following allogeneic or autologous HCT
human papilloma virus (HPV) - 3 doses more than 6 to 12 months following allogenic or autologous HCT for patients up to age 45
influenza (injectable) - 1 annual dose 4 to 6 months following allogeneic or autologous HCT
meningococcal conjugate - 1 to 2 doses 6 to 12 months following allogeneic or autologous HCT
pneumococcal - 3 doses of conjugated 13-valent vaccine 6 to 12 months following allogeneic or autologous HCT
recombinant zoster (commonly known as shingles vaccine) - 2 doses 50 to 70 days following autologous HCT, may be considered following allogeneic HCT but efficacy is unclear
Recommended Live Vaccines:
measles/mumps/rubella (MMR) - 1 to 2 doses more than 24 months following allogeneic or autologous HCT if no graft-versus-host disease (GVHD) or ongoing immunosuppression is observed
varicella vaccine (commonly known as chickenpox vaccine) - 1 dose more than 24 months following allogeneic or autologous HCT if no GVHD or ongoing immunosuppression is observed
zoster vaccine (commonly known as shingles vaccine) - 1 dose more than 24 months following allogeneic or autologous HCT if no GVHD or ongoing immunosuppression is observed
Benefits and Limitations of Vaccines
With the latest advances in vaccines, research from the European Myeloma Network states that myeloma patients usually tolerate inactivated vaccines with minimal side effects. However, patients with uncontrolled remission, severe immunosuppression, or severe allergic reactions to specific vaccines or their ingredients are generally advised against vaccination with live vaccines. Patients may experience minor swelling, redness, or pain with vaccination. More severe side effects like headaches, fever, chills, fatigue, joint and muscle aches are rarely experienced. More severe side effects like Guillane-Barre syndrome, anaphylaxis, spasms of the bronchial tubes are extremely rare with an occurrence in about 1 in every 1 million multiple myeloma patients.
With infections being the second leading cause of death in myeloma patients, vaccines are an important part of myeloma patient care. Vaccinations are an especially vital component of care for myeloma patients who plan to undergo autologous or allogeneic stem cell transplants because of their significant drop in antibody levels. The compilation of research by the European Myeloma Network provides a helpful roadmap for care. As always, make sure to talk to your care team about questions you have regarding your specific multiple myeloma diagnosis, treatment and care.
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Sources
Heinz Ludwig, Mario Boccadoro, Philippe Moreau, Jesus San-Miguel, Michele Cavo, Charlotte Pawlyn, Sonja Zweegman, Thierry Facon, Christoph Driessen, Roman Hajek, Melitios A. Dimopoulos, Francesca Gay, Hervé Avet-Loiseau, Evangelos Terpos, Niklas Zojer, Mohamad Mohty, Maria-Victoria Mateos, Hermann Einsele, Michel Delforge, Jo Caers, Katja Weisel, Graham Jackson, Laurent Garderet, Monika Engelhardt, Niels van de Donk, Xavier Leleu, Hartmut Goldschmidt, Meral Beksac, Inger Nijhof, Niels Abildgaard, Sara Bringhen and Pieter Sonneveld. Recommendations for vaccination in multiple myeloma: A consensus of the European Myeloma Network. Leukemia website. Accessed February 26, 2021. https://www.nature.com/articles/s41375-020-01016-0
