What is your approach to vaccinations and titers for patients with myeloma, who are immunosuppressed and do not have appropriate antibody responses to vaccines?
For an immunosuppressed myeloma patient who does not have an appropriate antibody response to vaccines, which of the following strategies would you consider?
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It depends on the vaccine and prior immunization history. Not all vaccines require an antibody response to be at least partially efficacious.
In addition, with any immunocompromised host, reduced effectiveness for all vaccines is expected, but is not a reason to not vaccinate. Serologic testing is helpful in some situations, but not all. When in doubt, when there is an exposure, it may be reasonable to employ post-exposure prophylaxis protocols.
For example, tetanus: if the patient was vaccinated as an adult while healthy, there is a reasonable chance they still have a circulating antibody. Some European vaccination schedules recommend a single adult dose of tetanus-containing vaccine, and then not again until age 65 if healthy. If the antibody is detectable at protective levels pre-vaccination but does not rise with vaccination, I'm not sure I would pursue further.
Pertussis, on the other hand, has antibodies which are measurable, but not necessarily directly correlated to protection. In the case of potential exposure, I would manage with post-exposure antibiotic prophylaxis. I would also manage HBV exposures with appropriate PEP.
Inactivated viral vaccines such as VZV and Covid do not necessarily need a detectable antibody response to confer some degree or protection. Regardless in these scenarios, the patient would likely receive antiviral PEP or treatment.
As mentioned previously, in the case of profound hypogammaglobulinemia, standing IVIG can be beneficial, and would be expected to contain antibodies against many vaccine-preventable diseases.
In the case mentioned, depending on the timeframe, it may be reasonable to wait until the immune system has reconstituted and try again.
I think it’s reasonable to try revaccination. However, if the patient is developing infections and the quantitative immunoglobulins are low enough to meet the criteria, the oncologist should be perfectly competent to prescribe IVIG instead of involving another specialist. It’s pretty standard practice with myeloma specialists to monitor this.
This depends on the treatment course and the vaccine being administered. If the initial response to something like TdaP or the pneumococcal vaccine is poor, it is reasonable to repeat the vaccine 6 months to 1 year later, particularly if immunosuppression is reduced during that time period. If, at that point, they do not respond, we often refer them to allergy/immunology for a more comprehensive immunodeficiency workup and consideration of IVIG replacement.