What vaccinations are recommended to mitigate serious 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 new 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 high 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 revaccinated 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 that flu getting to you is going to be much less.

What other vaccinations should myeloma patients be getting and are there any vaccinations that they shouldn't get?

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 everybody should get. Okay. So, sadly, as you get a little bit older and as I've just discovered, you are supposed to have the shingles vaccine. Again, there are two versions of that. The one that's available in the US is okay, It's not a live vaccine and we should be thinking about getting that. 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, then pneumonia vaccine, That's an important one. There's also one against a specific type of pneumonia. So different to the new one. One called Haemophilus influenza. And we should be thinking about having that one, too.

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 genetic 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 a 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, 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? Okay. 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 titers. And then if the patient's titers 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, 3 to 6 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. There 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 placental diseases 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. We recommend to get the normal coccal vaccine, we recommend to get the Tdap booster vaccine. We, in addition, recommend to get Shingrix vaccines once they're available before the patient. We also recommend to get COVID vaccines and in addition, the booster vaccine for the COVID specifically because we know that patients with impaired immune systems may have an optimal response to 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 that we recommend tandem flu vaccine in the fashion that we use the high dose flu vaccine rather than the normally dosed 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 the two-dose flu vaccine age-dependent or recommended 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, I mean, 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 been used in a tandem fashion that we use of one vaccination, and then it's recommended after 2 to 6 months to do a second vaccination to further increase the immunity against the herpes virus.

Do you still need to take acyclovir after receiving a shingles vaccine? Most likely, yes. So I personally keep all my patients on acyclovir 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 a Shingrix vaccine, they are still at a higher than usual risk for getting a virus infection such as shingles. And though our recommendation that everyone who is on proteasome inhibitors such as Bortezomib, Carfilzomib, Ixazomib should remain on acyclovir despite the fact that they have been vaccinated with Shingrix before.

So vaccinations, as we know, are such an important, protective measure from some of these infections, particularly with the Covid 19 pandemic that we've had over the last few years. Now we're entering that season again, you know, the flu season where we start to see more infections. And we've just had the recent approvals for the new Covid 19 booster, which is going to hopefully cover some of the new strains that have come up since the last time they updated it. So what we typically encourage, patients is to get all the vaccines that are available. That includes Covid, that includes the flu shot. And it also now includes the RSV vaccine, which was just come out. RSV was a virus that we saw a lot of actually the previous, spring and late part of winter, which, you know, led to quite symptomatic patients, you know, a lot of cough that was very much prolonged. And people can get pretty sick from that as well. To have a vaccine against that, I think is great. So we do typically encourage patients to get all three. They don't have to get all three at the same exact day or same exact time, so we do stagger. It doesn't have to be staggered by more than a few days, etc. So whatever you're able to accommodate with your schedule, that would be okay. But we do encourage you to get it. Furthermore, like where that fits into your treatment, you know, what we typically recommend is do not get it the day of your treatment when you're getting dexamethasone or other therapies that are going to block, you know, your immune system. So we typically want patients to get it on kind of in the middle part of their cycle or during their off week, from some of the therapy. So some of it is, you know, very much depending on what regimen they're on. But we do typically want patients to get all the vaccines and try to do it, if you can, in the middle of your cycle, just not in the day of the actual treatment.