Why do blood cancer patients need vaccinations?

For the general population, there are two types of vaccines:

• Non-live vaccines: These consist of an inactivated toxin or protein fraction from the infecting organism, which is developed so that it can generate an immune response.
• Live-attenuated vaccines: These contain whole bacteria or viruses which have been weakened (or attenuated) so that it can create a protective immune response, but does not cause the disease for people with healthy immune systems.

Both of these type of vaccines stimulate the immune system to create antibodies to the disease, which will protect you when you come into contact with it in the future. While the non‑live vaccines do not produce an immune response as strong as the live-attenuated vaccines, they are much safer as they do not contain a live strain of the bacteria or virus.

Patients who are immunosuppressed should not receive live-attenuated vaccines. However, your family may receive them in order to help protect you. Find out more in the ‘Should family members of blood cancer patients be vaccinated?’ section of this article.

It is important that patients who are immunosuppressed do not receive live-attenuated vaccines, particularly when they are receiving chemotherapy. This is because immunosuppressed patients can be at risk of a severe infection from the live vaccine strain contained within the vaccine. Non-live vaccines, however, are safe for immunocompromised patients and your haematologist can advise you when it is best to have them. Full details of immunisations for immunocompromised persons are available from the Health Service Executive (HSE) National Immunisation Office, at https://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/chapter3.pdf.

Examples of non-live and live-attenuated vaccines include:

* Tetanus, diphtheria and whooping cough vaccines are often combined in a vaccine called DTaP in young children and Tdap in adolescents and adults.
** Measles, mumps and rubella are often combined in a vaccine called MMR.
*** From 1st of September 2023, all eligible individuals will be offered the non-live shingles vaccine Shingrix instead of Zostavax. The eligibility criteria regarding immunocompromised patients has been updated – please see the toggle below called ‘Can I have the Shingles vaccine?’

The pneumococcal and meningococcal vaccines protect against infections which are responsible for pneumonia, septicaemia (blood poisoning), and meningitis.

The most beneficial vaccinations for immunocompromised patients are against the influenza virus (flu), Streptococcus pneumoniae (pneumonia) and hepatitis B virus. For all patients who are not on active treatment, the yearly flu vaccine is recommended.

If you’re travelling abroad at any point, then you may be required to have other vaccinations. It is important that you speak with your medical term before receiving any to make sure that it is safe for you to have them, or if there is an alternative.

An influenza infection can cause significant medical problems and can result in a higher chance of death for patients with a blood cancer and those who have undergone a hematopoietic stem cell transplant. The flu vaccination produces immune responses in patients with haematological cancers, although at lower rates than in healthy adults.

Flu vaccinations should be repeated yearly as the virus is generally different each year. These should be timed to be at least two weeks before chemotherapy or after chemotherapy. More details on the flu vaccine can be found on our website at: https://www.leukaemiacare.org.uk/support-and-information/information-about-blood-cancer/living-well-with-leukaemia/vaccines/flu-jab

The Department of Health states that patients who are immunosuppressed should be offered pneumococcal vaccination (against Streptococcus Pneumoniae) in the form of pneumococcal conjugate vaccine (PCV13 or Prenvar 13 ^®) followed by pneumococcal polysaccharide vaccine (PPV23 or Pneumovax ^®), at least two months later. The response to the vaccinations may be weaker and of shorter duration in patients with poor immune systems compared to normal.

Responses (antibody levels to the bacteria) can be monitored following vaccination. Assessing response following vaccination is useful to identify when a booster immunisation may be needed. For people with normal immune systems a booster is required every five years but it is typically a shorter time for Haematology patients.

Adults aged 65 and over are vaccinated through the routine older adult programme, which is administered as a single dose of PPV23. This is given regardless of the immunocompromised status of the individual. Your GP surgery will usually contact you when you are eligible to get your vaccine. If you think you should be eligible but have not been contacted, please contact your surgery.

You should always speak with your medical team who will advise which vaccinations are right for you and when you should have them. If you think it might be helpful, show them this article and use it to start discussions.

Before treatment

When possible, patients should be vaccinated prior to their planned schedule for chemotherapy. Non-live vaccines should preferably be given at least two weeks before starting chemotherapy, or three months after chemotherapy is finished.

During treatment

Vaccination of patients while they are receiving chemotherapy is not advisable. For a vaccine to be effective, a relatively healthy immune system is needed to achieve an adequate response.

After treatment

Immunity from vaccinations received before chemotherapy treatment is reduced after treatment. Antibody levels measured six to 12 months after chemotherapy vary according to the vaccine. Therefore, it is possible that patients may need re-vaccinating for diseases they have previously been vaccinated for in childhood, while others may only require boosters.

Additionally, the HPV non-live vaccine which offers protection against cervical, vaginal, vulvar and penile cancer, anal cancer and throat/tonsil cancer should be considered.

In children, giving booster immunisations, including diphtheria-tetanus, inactivated polio and measles-mumps-rubella (MMR) vaccines, six months after chemotherapy is recommended.

Following a stem cell transplant (allogeneic or autologous) patients lose their immunity to poliovirus, tetanus, diphtheria and measles and are at increased risk of developing infections caused by bacteria such as Haemophilus influenzae and Streptococcus pneumoniae. Consequently, post-transplant re-immunisation is mandatory usually six to 12 months post-transplant.

Vaccination for measles-mumps-rubella with a live attenuated-virus is not generally recommended as patients can be at risk of fever, pneumonia or disease from the vaccine strain. However, in the event of an epidemic of measles, your haematologist will assess the risk versus the benefit of having the vaccination in view of the serious effect of measles on immunocompromised blood cancer patients.

Prompt antibiotic treatment for patients who are at risk and have a raised temperature is critical. Also, self‑isolation and good hygiene for blood cancer patients whose levels of neutrophil white blood cells are particularly low is important in helping to protect them from infection.

Vaccinations are appropriate for family members of patients with a blood cancer during their chemotherapy treatment; however, family members are advised to request the inactivated types of the vaccines. For example, the inactivated poliovirus vaccine is more appropriate for family members than the oral polio vaccine.

Since flu is a highly contagious, seasonal illness can have severe complications in blood cancer patients, it is recommended that all family members and people you live with are vaccinated before the start of flu season to keep you safe.

In children, the flu vaccine is given as a nasal spray which uses the live-attenuated influenza vaccine. Therefore, appropriate measures should be taken to prevent any contamination with the live-attenuated virus from any family members who have received the vaccine.

Simple ways to help avoid infection:

• Wash your hands regularly.
• Maintain good personal hygiene. Take extra care to keep your mouth clean.
• Avoid people with an infection or any crowded places where there is a risk of infection.
• Avoid foods that may contain harmful bacteria.
• Drink plenty of fluids.

If you would like any more information about how best to avoid infection, talk to your nurse who will be able to offer tailored advice.

For more information on the COVID-19 vaccination, please head to our FAQ blog here: https://www.leukaemiacare.org.uk/support-and-information/latest-from-leukaemia-care/blog/covid-vaccine-faqs/

As with live-attenuated human vaccines, pet vaccines that contain liveattenuated bacteria or viruses present a risk for people who are immunocompromised. It is important for immunocompromised patients to make their vet aware of their immunocompromised status.

Immunocompromised pet owners should request the inactivated type of the vaccine for their pet. However, most vaccines for pets are now liveattenuated (also called modified live vaccines) as they are more effective.

Following immunisation of a family pet with a liveattenuated vaccine, the advice is to avoid close contact with the pet for an appropriate period of time. Your vet will be able to advise you as to the optimum time to avoid close contact with your pet.

As an example, live-attenuated vaccines for Bordetella bronchiseptica (Kennel Cough) are available for dogs and cats. The administration of the vaccine is intranasal and it is recommended to avoid contact with the vaccinated pet for a period between 35 days to 11 weeks. However, a new non-live Kennel Cough vaccine to be administered by intramuscular injection has currently been licensed.

Core (essential) and non-core vaccines for dogs and cats are listed in the table below.

Core and non-core vaccines for cats and dogs

Details of vaccines for rabbit and ferrets are shown on the British Small Animal Veterinary Association (BSAVA) website.

As someone who is immunocompromised, you will be used to saying that you aren’t able to have any live vaccines. But what about when your dog needs to have one?

Kennel cough is a highly contagious respiratory disease that can spread easily amongst dogs. It can be caused by a number of different germs, and can spread quickly in close-contact environments such as kennels. 

For that reason, it is recommended that dogs receive a kennel cough vaccination (KC). This is a live vaccine that is typically given to the dog through a nasal spray that includes a weakened strain of the main disease-causing bacteria Bordetella bronchiseptica. 

As KC is a live vaccine, there is an extremely small, theoretical risk that the bacteria could potentially cause infection in immunocompromised humans. However, it is important to note that a dog with kennel cough is a far greater risk to immunocompromised individuals than pets who have received the vaccination, meaning it is still very important to get your dog vaccinated. 

If your dog has recently been infected with kennel cough or was recently vaccinated and you develop pneumonia, please do be sure to bring this to the attention of your haematologist. 

If you have any further questions or concerns about the KC vaccine and your health, you should discuss them with your haematologist, and also with the vet before they administer the vaccine.

From the 1st of September 2023, the non-live shingles vaccine (Shingrix) will be made available to those who are immunocompromised aged 50 or above. This means that nearly 1 million more people will be eligible to receive the vaccine going forward, including many blood cancer patients in all UK nations. 

In addition to this, patients aged 18-49 who are due to undergo a stem cell transplant or CAR T therapy will also be eligible for the vaccine under the updated guidance from the Joint Committee on Vaccination and Immunisation (JCVI).

For more information on this update, please find our full blog here.