Saturday, September 12, 2009

Vaccination for the coming winter.

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.


justme said...

Thanks for this!

Anonymous said...

I have cll and have been through FCR, but I seem to be having much less trouble with flu and colds than I did before I got cancer. The month I was diagnosed (6/05), I spent a few days in the hospital with what my doc said was "probably" pneumonia. Since then, however, I've had no problems. So, the shots seem to be working on me. I've had none of the auto-immune diseases, shingles, or any of that.

Have I just been lucky, or are there patients who are like this, who don't seem to lose so much of their immune function?

Terry Hamblin said...

It is clearly more complex than my summary. I had one patient with recurrent herpes whose condition remitted on FCR. Both CLL and its treatment cause immunosuppression. Sometimes clearance of the CLL improves the immunodeficiency, notwithstanding teh effect of FCR, but it is not predictable, and the IWCLL and NIH guidelines have both said that immunodeficiency is not an indication for treatment.

Anonymous said...

From the time I was diagnosed, I went 19 mos on W&W until FCR. During this time, I had no infections, etc., except the "pneumonia" I mention in my reply above. And have had none in the 2 1/2 yrs since. Prior to FCR, I had a a huge spleen, pan-cytopenias, and 70% marrow involvement.

Before I knew I had cll, I had had colds and the flu a lot. But afterward, I started taking flu shots and have had almost none.

So, it seems to me that the vaccinations have been working on me the whole time I've had cll, before and after FCR.

Irving Noble said...

What is the reason for taking 300 ml Rantinidine twice a day for 90 days after the first flu shot?

My oncologist has suggested two flu shots, the first in Nov. and the second in Feb. Why would waiting six weeks between injections be a better alternative?

Irv Noble, 75
Chlorambucil 2 treatments
FC + Dex. 5 treatments, now in remission for maybe 2 years.

Terry Hamblin said...

The Ranitidine data are from Jurlander's paper some years ago. It is suggestive rather than proven, but if the ranitidine is harmless then it is worth a try. Of course if ranitidine causes side effects then it should be avoided. Boosts in immunology are usually given between 2 and 6 weeks after the primary injection.

briscardo said...

How does Ranitidine (called Zantec, an antacid in USA) work with the Flu shot?
Is it possible that Rimantadine is meant?
How can I find the Jurlander paper referred to?