CLL: Infection Kills! How Can We Prevent It?

By Deborah M. Stephens, DO

I have got tons of extra white blood cells. That helps me to fight infection, right?

Wrong. Although normal white blood cells fight infection, abnormal white blood cells (such as CLL cells) do not help your body fight infection. Patients with CLL are more likely to get infections than your peers without CLL. Infection is actually a major cause of death in CLL patients. The risk of infection is increased with higher Rai Stage of disease and receiving treatment for the CLL. Therefore, patients with CLL need to take additional precautions to prevent contraction of infection.

Do I need to live in a bubble and always wear a mask and gloves?

No. The best way to avoid infection is frequent and effective hand-washing. Additionally, it is recommended that you receive appropriate vaccines, including a yearly influenza vaccine in the fall and a pneumonia vaccine every 5 years. The influenza vaccine should be the shot and not the one that is squirted into the nose. The nasal vaccine contains live particles of virus and is not appropriate for CLL patients. (This nasal influenza vaccine is no longer routinely manufactured.) For patients with CLL, the pneumonia vaccination should be given in two separate visits. The first vaccine is the 13-valent pneumococcal conjugate vaccine (PCV13; Prevnar 13). The second pneumonia vaccine is the 23-valent pneumococcal polysaccharide vaccine (PPV23; Pneumovax 23), which should be given at least 2 months after the first vaccine. Keep in mind, that the pneumonia vaccine does not protect against every bug that causes pneumonia, it only protects against the most common type of bacteria that causes pneumonia, called Streptococcus pneumoniae. Also keep in mind that the pneumonia vaccines will not be as effective in someone with CLL compared to someone without CLL. A CLL patient’s immune system will not be able to make as strong of a response to the vaccine. In fact, it has been reported that <20% of CLL patients will make an effective immune response to the PPV23 and ~60% of CLL patients will make an effective response to the PCV13 when the vaccines are given alone1,2. Therefore, the current recommendation is for CLL patients is to receive both vaccines to give the most protection possible with the understanding that we can’t prevent 100% of pneumonias. In other words, some protection is better than no protection.

Are there any other vaccinations that I should consider?

Yes, the other vaccinations that are recommended for patients with CLL based upon the Clinical Practice Guideline for Vaccination of the Immunocompromised Host written by the Infectious Disease Society of America and are as listed in Table 1. You and your doctor can find a full article of these recommendations here.

Table 1.  Other Recommended Vaccinations for Patients with CLL

Vaccine Name

Who Needs It?

How often?

Tetanus, diphtheria, pertussis (Td/Tdap)

Everyone

Tdap one time and Td booster every 10 years

Hepatitis A

People who:

-work in medical or research field.

-travel to countries at risk for Hepatitis A.

-have adopted a child from these countries.

-have human immunodeficiency virus (HIV). 

Men who have sex with men.

One time 2-3-dose series

Hepatitis B

People who:

-work in medical or research field.

-travel to countries at risk for Hepatitis B.

-have adopted a child from these countries.

-live with someone who is known to have Hepatitis B.

-have HIV. 

-participate in high-risk sexual activity or drug use.

One time 3-dose series.

Meningococcal 4-valent conjugate (MenACWY)

People who:

-have had their spleen removed or radiated.

-have HIV.

-work in medical or research field.

-travel to countries at risk for Hepatitis A.

-are in the military.

Two-dose series every 5 years.

Haemophilus influenza type b (Hib)

People who:

-have had a bone marrow or stem cell transplant.

One time 3-dose series after transplant.

 

Are there vaccinations that I should not receive?

Yes. You should not receive any vaccines that contain live particles of virus or bacteria as these vaccines may cause the infection that the vaccine is trying to prevent. You can find a list of these vaccines in Table 2. The most common vaccine offered to CLL patients is the herpes zoster vaccine (shingles vaccine). This vaccine should not be given to CLL patients, and if a family member or someone who you have close personal contact receives the vaccine, you should avoid contact with that person for one week. Additionally, if someone close to you develops shingles or chickenpox, you should avoid contact with that person until all lesions are crusted in appearance (no blisters or open sores). If you have already received the shingles vaccine, don’t panic! If you did not develop a rash in the week following the vaccine, you did not contract the virus from the vaccine. Also, please keep watch in the news and ask your doctor for updates as there is a new “dead” or inactivated shingles vaccine being tested in clinical trials right now. This new inactivated shingles virus may be available and safe for CLL patients to receive in the future. You can find out more about this clinical trial here.

Table 2.  Live Vaccines that CLL Patients Should Avoid

Adenovirus

BCG (tuberculosis)

Live-attenuated influenza vaccine (nasal influenza)

Herpes Zoster (shingles)

Measles, mumps, and rubella (MMR)

Oral poliovirus (OPV)

Rotavirus

Smallpox

Oral Ty21a Salmonella typhimurium (oral typhoid vaccine)

Varicella (chickenpox)

Yellow Fever

 

Do I need to take antibiotics to prevent infection?

Possibly. The decision to start a CLL patient on preventative antibiotics is very personalized and should only be directed by your CLL doctor. Some CLL patients will need preventative antibiotics or antiviral agents because they have had multiple infections in the past or because they are on a specific anti-CLL treatment. Antibiotics also have side effects including the chance of resistant bacteria and other infections that happen when you kill all of your body’s normal bacteria (such as a severe diarrhea illness called Clostridium difficile or C. diff). Therefore, the decision to start a preventative antibiotic should only occur after a careful discussion of risks and benefits between you and your CLL doctor.

Some patients that have several severe infections (≥3) within a short time period (6 months). Your CLL doctor can check a blood level of proteins (called immunoglobulins) in your blood to see if they are low. CLL patients often have low numbers because the CLL cells don’t make enough of these proteins (immunoglobulins). If the numbers are low in your blood and your CLL doctor recommends it, patients can receive monthly infusions of immunoglobulins (intravenous immunoglobulin; IVIG) with the goal of preventing future infections. These treatments are time-consuming and have side effects, so they should only be started after a careful discussion of risks and benefits between you and your CLL doctor.

Who should I ask other questions about preventing infection?

The best resource to answer further questions is your CLL doctor. To find a local CLL expert, please visit the CLL Society’s Page for CLL Physicians Recommended by CLL Society Readers.

In summary, to prevent infections:

  • Keep your hands clean with frequent and effective hand-washing.
  • Follow the vaccine recommendations described above.
  • Consult with your CLL doctor about any specific instructions he or she has for you.

 

References

1. Hartkamp A, Mulder AH, Rijkers GT, van Velzen-Blad H, Biesma DH. Antibody responses to pneumococcal and haemophilus vaccinations in patients with B-cell chronic lymphocytic leukaemia. Vaccine. 2001;19(13-14):1671-1677.
2. Pasiarski M, Rolinski J, Grywalska E, et al. Antibody and plasmablast response to 13-valent pneumococcal conjugate vaccine in chronic lymphocytic leukemia patients–preliminary report. PLoS One. 2014;9(12):e114966. doi: 114910.111371/journal.pone.0114966. eCollection 0112014.

Dr. Stephens is an Assistant Professor and the Physician Leader of the Hematology Clinical Trials Division at Huntsman Cancer Institute. Her clinic focuses on patients with lymphoma and chronic lymphocytic leukemia (CLL). Her primary research interest is developing new targeted therapies for patients with lymphoma and CLL. She is an expert panelist for the National Comprehensive Cancer Network (NCCN) CLL Guidelines Panel, which establishes and published the most widely referenced guidelines for the evaluation and treatment of patients with CLL. She is also the Physician Leader of the SWOG CLL Working Group Committee, which is a group of CLL experts from academic centers around the country who plan and implement national clinical trials to improve the standard-of-care for CLL patients across the country.

Originally published in The CLL Tribune Q2 2017.

 

 

Information provided by CLL Society.