A group of leading myeloma specialists, known as the International Myeloma Working Group, recently collaborated to develop guidelines for the prevention of infections in multiple myeloma patients. The group recommends that patients receive inactivated vaccines for the flu, hepatitis B, and polio as early in the disease as possible. Patients at high-risk of developing infections can be given medications to prevent infections.

Dr. Elias Anaissie of the Myeloma Institute for Research and Therapy at the University of Arkansas for Medical Sciences presented these guidelines at the International Myeloma Workshop (IMW) in Paris last month.

Why Should Myeloma Patients Be Vaccinated?

In healthy individuals, plasma cells secrete antibodies to fight off infections, and the production of these antibodies is properly regulated. In most multiple myeloma patients, too many plasma cells are produced, which leads to increased levels of antibodies. Most of these antibodies are abnormal, however, so they do not function or fight off infection properly. As a result, myeloma patients have an increased risk for developing infections.

The guidelines recommend that myeloma patients receive vaccinations in order to increase protection from infection.

Which Vaccines Should Patients Get?

The guidelines recommend that patients receive vaccines for influenza, hepatitis B, polio, and other prevalent conditions. In addition, patients should receive the vaccine PPSV23 that protects against the virus responsible for pneumonia.

Vaccines can contain inactivated (killed) microorganisms or live but weakened microorganisms. The guidelines recommend that myeloma patients avoid live vaccines.  Live vaccines can be considered for patients with the early stage diseases monoclonal gammopathy of undermined significance (MGUS) or smoldering myeloma as well as at-risk myeloma patients in remission three to six months after completing chemotherapy.

Inactivated vaccines are available for the flu, polio, and typhoid.  Live vaccines are available for measles, mumps, and rubella (MMR), chicken pox (Varivax), shingles (Zostavax), typhoid (oral vaccine), yellow fever, the flu, and polio (oral vaccine).

Since live, vaccine-strain viruses may sometimes be transmitted from person to person, the guidelines recommend against some vaccines for close contacts of myeloma patients. If these individuals do receive live vaccines, they should, if possible, avoid direct contact with myeloma patients for four to six weeks after vaccination and follow careful hand hygiene.

When Should Patients Be Vaccinated?

In order to determine proper timing of vaccination, physicians should consider a patient’s susceptibility to infection and the risks or benefits of vaccination. The guidelines state that vaccines should be given as early as possible, such as during the MGUS or smoldering phases of myeloma.

For myeloma patients scheduled to receive anti-myeloma therapy, the guidelines recommend patients should be vaccinated at least 14 days prior to starting chemotherapy, prior to stem cell mobilization and collection, upon achieving best response to therapy, or three to six months after completing chemotherapy or six to twelve months after stem cell transplantation. It is possible for patients to be vaccinated between chemotherapy cycles, but the effectiveness of the vaccination is likely to be significantly reduced.

Although travel to areas with high rates of disease is strongly discouraged, patients with travel plans to these regions should receive additional travel vaccines based on their itinerary. These vaccines may include typhoid, polio, meningitis, rabies, tick-borne or Japanese encephalitis, and salmonella.

Immunoglobulin Replacement

Replacement immunoglobulin (antibody) has not been shown to protect against infections; however, it may be considered for myeloma patients with very low immunoglobulin levels who suffer serious and/or recurrent infections.

Immunoglobulin replacement may be given intravenously, subcutaneously, or intramuscularly. Although the intravenous treatment is generally well tolerated, it increases the patient’s risk for acute kidney failure. Patients should receive acetaminophen (Tylenol), antihistamines, and glucocorticoids 30 minutes prior to the infusion to prevent and minimize the severity of infusion-related side effects.

By comparison, subcutaneous administration leads to fewer systemic reactions and more consistent levels of immunoglobulin in the blood. It is also less expensive than intravenous administration and does not require access to veins or premedication. However, it requires more frequent injections, and local reactions may occur.

Medications To Prevent Infection

Myeloma patients who are at high risk for developing serious infections may receive preventative antimicrobial medications. Physicians should determine a patient’s risk for infection by assessing his or her age, disease activity, prior therapy type and extent, organ function, and laboratory results.

Patients who are exposed to chicken pox or shingles should receive treatment with acyclovir (Zovirax) and VariZIG IM within 96 hours of exposure, if they are not already immune.

Additional Preventative Measures

Myeloma patients should maintain good personal hygiene in order to reduce their risk of developing an infection. The guidelines recommend frequent hand washing, teeth brushing after meals, and protection during sexual encounters with partners who may have sexually-transmitted diseases. For patients treated with bisphosphonates for bone disease, it is important to not share toothbrushes and to change toothbrushes every three months.

The guidelines also recommend that patients avoid environmental exposures that may put them at risk of developing an infection. For instance, patients should avoid exposure to individuals with infections or with recent vaccination from live vaccines. They should thoroughly wash and cook fruits and vegetables prior to eating. They should avoid any at-risk recreational or outdoor activities, such as swimming in public places or exploring caves, and patients should only be exposed to pets with updated and appropriate vaccinations.

In addition to receiving location-specific vaccinations, all patients with travel plans should assess their immune status prior to traveling. The guidelines also recommend that patients minimize insect bites with insect repellant and receive antimicrobial medication to prevent malaria, tick-borne disease, and other infections. Strict food precautions should be followed to prevent traveler’s diarrhea.

For more information, please see Dr. Anaissie's slide deck ^[1] (pdf).