Myeloma 101: Vaccinations After Myeloma Stem Cell Transplant

BY PAUL KLEUTGHEN Should myeloma patients get re-vaccinated after stem cell transplant? Experts say there are benefits in doing so. An article was published last week coming from this year’s Oncology Nursing Society’s Annual Conference that was titled “Guideline-driven Initiative Improves Pneumococcal Vaccination Rates Among aHSCT Recipients”, authored by Joyce Pagan, May 4, 2017. Of course, aHSCT, stands for autologous hematopeitic stem cell transplant. There are several interesting comments made in this article :

• “Influenza-associated pneumonia rates are significantly higher among HSCT recipients than in the general population (7% to 35% vs 2% to 8%, respectively). This difference underscores the importance of immunizations in mitigating vaccine-preventable diseases in this patient population.”
• “Guidelines from the Centers for Disease Control and Prevention, the Infectious Disease Society of America, and the European Group of Blood and Marrow Transplantation recommend serial re-immunizations on recovery from aHSCT (full reconstitution of the immune system takes 1 to 4 years). Initial recommended vaccines are seasonal influenza, pneumonococcal, and haemophilus influenza B conjugated vaccines, administered within the first 6 months.”
• “ … less than 40% of aHSCT recipients received their initial pneumococcal vaccine within 1 year post-aHSCT, with less than 60% of those patients completing the series..”

I was surprised to read that only about one quarter of SCT patients complete the pneumococcal vaccine series. Before my tandem auto-SCT at the Duke Adult Bone Marrow Transplant center I was told that all my childhood vaccinations (and others received later in life) would be wiped out from the transplants and, that post-transplant, I would be receiving a whole bank of revaccinations spread over several years. Just out of curiosity I checked the practices at a few other large transplant centers that I could readily find through internet searches. Let me share a few here :

• Fred Hutch in Seattle recommends the following : “We recommend that patients receive the most common vaccinations one year after their transplant. These include: diphtheria, tetanus, Haemophilus influenzae type B, Streptococcus pneumoniae, Salk poliovirus (inactive virus) and influenza (annually). Children less than 7 years of age should also receive the pertussis vaccine. Hepatitis A and B vaccines may be recommended for certain patients. If blood tests show that immunity has waned, we may recommend additional vaccination doses. Other vaccinations may be recommended on an individual basis by your healthcare provider.” “Transplant patients should definitely NOT receive the smallpox vaccine because it is made from a live virus (vaccinia) and can cause vaccinia infection. It is also important that patients NOT receive the measles, mumps, and rubella (MMR) vaccine until two years post-transplant and at least one year after discontinuing immunosuppressive therapy. The same is true for other live-virus vaccines, such as BCG, oral (Sabine) polio, yellow fever, and typhoid. The Varicella-zoster (chickenpox/shingles) vaccine is currently not generally recommended, pending further research. If the benefits outweigh the risks, it may be given to help prevent chickenpox if the patient doesn't already have antibodies to the chickenpox virus.” They also provide a nice summary of why this important.
• MD Anderson also provides a nice summary of why revaccination after STC is important and their website provides a summary table of their standard practice.

The Centers for Disease Control and Prevention (CDC) have provided very extensive guidance on this topic titled “Guidelines for Preventing Opportunistic Infections Among Hematopoietic Stem Cell Transplant Recipients” This link takes you directly to a table of recommended immunizations that looks very similar to the MD Anderson table. This table is part of quite a lengthy, though very interesting, document that will give you some food for thought if you have not yet been revaccinated yet post-transplant. Practices may vary from MM treatment center to center but, if you have not yet been revaccinated post SCT, you may with to discuss this topic with the physician(s) who treat/manage your disease.