What vaccinations should myeloma patients be getting to help prevent infections?

What vaccinations should myeloma patients be getting to help prevent infections? So there's always lots of discussion about the flu vaccine. And I think that ideas have potentially changed quite a lot over the last few years as well. So it always used to be said that patients could get the flu vaccine, but it maybe wasn't worth it because it didn't work. However, there's some newish more kind of data that has come out to suggest that actually, in many patients, it really does work. And I think from my own perspective, I would argue that it doesn't do any harm. And so therefore, all patients should get the flu vaccine. One of the questions that comes up is there's a number of different types of flu vaccine. So there's a high dose flu vaccine and a normal dose. So which one of those two should a patient get? The second thing that comes up is do you just need one flu vaccine or should you actually get two flu vaccines? Because what seems to be happening is if you have your flu vaccine early in the season, say September, then your protection may wane by the time you get to February or March. And flu season can often go on to April or May. These are all completely unanswered questions. And definitely one of those, if you ask two myeloma doctors, you'll get six answers. For the very simple reason, nobody really knows. So I would argue that you get the flu vaccine that you can actually get. That's number one. If the higher dose one is on offer, then I think that is definitely useful. And then I would say that actually one of the important things to some extent is whether you're on treatment or off treatment. Because to some extent, some patients who are on treatment, the vaccine may not be quite as effective. And so potentially having that higher dose vaccine or indeed getting re-vaccinated later on in the flu season is potentially a good idea. So there's no definite answer there. So you can't do a wrong thing. But I think definitely the right thing is get yourself vaccinated and ideally get everybody else around you vaccinated. Because that kind of gives you a little bit of a comfort blanket in the fact that if potentially the rest of the household is vaccinated, the chances of the flu getting to you is going to be much less. So there's a number of different kinds of vaccines. There are what we call live vaccines and then either engineered or dead vaccines. And as a general rule, we don't like live vaccines. So a live vaccine is when you take a little bit of the disease or the protein and you give it to somebody. And the reason we don't like that is if you've got an immune system, that little bit your body can fight. If you don't have an immune system, that little bit they give you might actually give you the disease. So I have to say nowadays, most of the vaccines that we're using, unless you're going on holiday somewhere exotic, are actually either dead vaccines or kind of engineered vaccines. So it's not so much of a problem. Now, as far as what vaccines should patients get? So we should be having the ones that everybody should get. OK. So sadly, as you get a little bit older, as I've just discovered, you are supposed to have the shingles vaccine. OK. Again, there are two versions of that. The one that's available in the US is OK. It's not a live vaccine. And we should be thinking about getting that. OK. That's a double shot. You have to have one three months apart. We should be thinking about having flu vaccines, COVID vaccines, but then some of the more regular ones as well. So again, if you're a little bit older, the pneumonia vaccine, that's an important one. There's also one against a specific type of pneumonia. So different to the Pneumovax one, one called Haemophilus influenza. And we should be thinking about having that one too. OK. So essentially, more or less any vaccine you're offered, as long as it's not live and the ones that are appropriate for your age group, we should definitely be having. However, we do need to have a chat with your local oncologist about when is the best time to get a vaccine. Because if there's an opportunity and you're on treatment, it may be better to have it either at the beginning of the treatment or the end of the treatment. So it has the maximum chance of working. Should patients be revaccinated with childhood vaccines after stem cell transplant? So the other time we need to think about vaccines is after a patient has had a stem cell transplant. And the advice is slightly different depending whether you had your own stem cells back, so an autologous transplant, or whether you had somebody else's cells, an allogeneic transplant. And I'm going to put the allogeneic transplant to one side because that advice is very different. And also for myeloma patients is probably not so common. So if we think about the autologous transplant, when you have your own cells back, what will usually happen is we'll start thinking about it at about the three month mark. So after those cells have had chance to settle down and start to grow. However, there's all sorts of discussion and debate amongst doctors about exactly which vaccinations are appropriate and what is the best way to go about it. Because the question is, is when you have your own cells back, do all of those vaccinations you had as a baby or in your childhood, do you still have immunity to them or not? OK, and there's two ways of looking at it. Some people say, well, actually, we'll check the blood and we'll see whether patients have immunity to it. So we'll check their TITAs. And then if the patient's TITAs are good or not so good, then we'll do the vaccinations. Whereas other people will say, well, actually, don't bother checking the blood. We'll just give them to you anyway. And so usually at about that three month mark, three to six months, we'll at least think about what is the most appropriate way for patients to have those vaccinations. And what I would suggest to do is you have a chat with the transplant team as to what their standard guidelines are. We do have some standard guidelines, but as I say, everybody does them a little bit differently. So have a chat with the local transplant team who did your transplant and ask for their advice about which is the most appropriate. Patients with plasma cell disease such as multiple myeloma should receive the common vaccinations that are recommended for patients in the age group. In particular, it's important to stay on track with the booster shots and with the appropriate age for vaccination or revaccination, because we know that patients with multiple myeloma have a potential decrease in response after vaccine to develop the appropriate immunity against the diseases they are vaccinated against. So we recommend to get the normal carcal vaccine. We recommend to get the booster vaccines. We in addition, we recommend to get shingrix vaccines once they're available for the patient. We also recommend to get covid vaccines and in addition, the booster vaccine for the covid vaccine specifically, because we know that patients with impaired immune system may have a suboptimal response to the two now available covid vaccines. With changing guidance from the FDA, it is best to have a discussion with your oncologist when new recommendations are issued. Should myeloma patients consider getting a second dose of the flu vaccine? The flu vaccine is recommended for patients with multiple myeloma on a yearly basis. And what we know is based on more recent studies is that we recommend a tandem flu vaccine in the fashion that we use the high dose flu vaccine rather than the normally dose flu vaccine. And we recommend a booster one month after the initial vaccine because it's been shown to further increase the immunity against the common flu strains that are out there. Is getting vaccines age dependent or is it for all myeloma patients? This is for all myeloma patients in particularly after transplant, but also for patients who do not receive high dose chemotherapy. I think the data is very strong that we see that two vaccines are better than one vaccine and further increase the antibody levels against the flu virus. What shingles vaccines are available? So to my knowledge, we mostly switch to the shingrix vaccine, which is an inactivated virus vaccine, which does not contain any viable virus and therefore is not in any way harmful for our patients because there is no viable virus material in the vaccine that potentially could reactivate and potentially cause virus infection. So shingrix is a product that's been used. It's also being used in a tandem fashion that we use one vaccination and then it's recommended after two to six months to do a second vaccination to further increase the immunity against the herpes virus. Do you still need to take a cycloveur after receiving a shingles vaccine? Most likely, yes. So I personally keep all my patients on a cycloveur despite they received the shingrix vaccine. The reason is that the proteasome inhibitors make our patients more vulnerable for shingles infections or herpes reactivation. And even though the risk is significantly decreased for our patients after shingrix vaccine, they are still higher than usual risk for getting a virus infection such as shingles. And though our recommendation is everyone who is on proteasome inhibitors such as botasome, cathasome, boric, xasome should remain on a cycloveur, despite the fact that they have been vaccinated with shingrix before.