We are entering the flu vaccination period and I have been asked for advice for CLL patients.
The first thing to say is that CLL patients are very poor at responding to vaccines. If you have late disease and especially if you have been treated by a purine analog (Fludarabine, Cladribine or Pentastatin) of with Campath, it is very unlikely that you will respond to any vaccine. Your best hope of protection is to avoid infection - make sure that family members are vaccinated and avoid crowds (especially unvaccinated children). don't shake hands, don't share a common communion cup, avoid kissing unvaccinated people and wash your hands frequently. By all means get vaccinated but don't be too disappointed if it doesn't work.
As far as I can tell WHO advice (which dates from April 2009) still recommends that you have the seasonal flu vaccine.
The components recommended for the 2009/10 northern hemisphere influenza vaccine are as follows;
• A/Brisbane/59/2007 (H1N1)-like virus;
• A/Brisbane/10/2007 (H3N2)-like virus;
• B/Brisbane/60/2008-like virus.
This is the same as the 2008 vaccine, which many of you will have had, so having it this year boosts what is left of last year's immunity.
But since April 2009 we have had swine flu as a pandemic. This is also an H1N1 virus, but serologically different from the Brisbane virus present in the seasonal vaccine. It may be that it has similarities to the 1957-8 Asian flu pandemic since individuals over 65 do not seem to be suffering so severely from the new strain. Swine flu vaccines are being evaluated and should be available this month. The question is whether you will need both. The answer is we don't know. The recommendation, at least from the British Department of Health seems to be that one should have both, but I am not certain that experts have really addressed the issue. It really depends as to whether both strains of the virus will be infecting people this winter. From past experience it is the new strain that predominates.
Generally I advise CLL patients to have two flu shots at 6 week intervals and to take a big dose of ranitidine (300mg twice a day) for 90 days starting with the first injection. Whether this will work is still not established, but there are supporting papers for the idea. The imiquimod trial has not yet reported. I am not sure how to advise on what would potentially be 4 injections (2 seasonal, 2 swine).
Advice on pneumovax is very difficult. Response in CLL patients is virtually zero. This is because it is a polysaccharide vaccine to which CLL patients respond extremely poorly. In infants Prevnar 7 gives a better response (being a conjugated vaccine) and there is every reason to suspect that it would give a better response in CLL patients. However, it is designed for the 7 strains of pneumococcus that are present in 80% of infant pneumonias and may not cover as wide a range as the 23 strains in pneumovax. A Prevnar 13 is due out shortly, and in Europe a vaccine against 10 strains, Synflorix, is available. Again end stage patients and those who have had fludarabine are very unlikely to respond.
I'm sorry to be so uncertain, but that is the lie of the land at present. I will update this as time passes.