Vaccines

Vaccination in CLL

Vaccination in CLL is something I am always being asked about. It is not an
easy question.

All patients with CLL have an impaired immune response. I did some work in
1974 using an antigen that would have been new to all patients called phiX174.
I was surprised to find that even patients who had very minor CLL with normal
immunoglobulins could not make a primary response, though after repeated
injections some could produce a weak response. Others have found similar
results.

First, patients with CLL should never have live vaccines. Fortunately, very
few live vaccines are used today, the only common ones being Yellow Fever and
Oral Polio and measles.

Second, other vaccines may fail to boost immunity. This is particularly true
for polysaccharide vaccines like pneumovax which are almost uniformly
ineffective. Influenza vaccines produce responses in less than half of patients.

There are some tricks, though, that make vaccination more effective. If you
take ranitidine (ZANTAC) for two weeks over the vaccination period, this
doubles the response rate. Coupling polysaccharide vaccines to protein (so-called
conjugate vaccines) makes them work better. There are conjugate vaccines for
HIB and meningococcus and pneumococcus.

So it is sensible to be vaccinated, especially against 'flu when you have
CLL, but be sure to take Zantac during the vaccination period.

As for pneumococus the standard vaccines are almost guaranteed not to work
in CLL. There is a conjugated vaccine. In the UK the trade name is Prevenar,
made by Wyeth. Unfortunately, it is 4 times as expensive as the ordinary
pneumococcal vaccine retailing at 40 pounds sterling a shot. This is made
especially for children and I'm not sure that it is even licensed for adults. I do
not believe that there has been trial of this vaccine in CLL and it has the
disadvantage of only being active against 7 serotypes rather than the 23
available in Pneumovax II. Again taking it with ranitidine would seem to be
sensible.

Clinical trials in CLL seem to concentrate on trying to cure the disease
even though most patients have to learn to live with their disease. A trial of
vaccination using the conjugate pneumococcal vaccine with and without
ranitidine would be a great idea.

Here is the abstract from a review published last year:

Chronic lymphocytic leukemia (CLL) is a well-defined mature B-cell neoplasm
associated with increased susceptibility to infections. Two major options in
prevention of infections in CLL, intravenous gammaglobulin treatment and
antimicrobial chemoprophylaxis, have not resulted in satisfactory outcome. A
third strategy, antimicrobial vaccination, is the topic of this minireview. We
collected articles and their references concerning CLL vaccination from the
Medline database starting from 1966 and thirteen relevant studies were found.
Plain bacterial polysaccharide vaccines would seem to be ineffective in antibody
formation in patients with CLL. However, protein and conjugate vaccines
appear to be more immunogenic and their responses may be further enhanced with
ranitidine adjuvant treatment. New well-designed investigations are needed to
develop appropriate vaccination strategies and evaluate vaccination efficacy
in infection morbidity and mortality in CLL.

Vaccination and ranitidine.

I need to clarify my two previous postings on this.

First, because of the impaired immunity in CLL, patients make very poor
responses to protein vaccines and none at all to polysaccharide vaccines like
pneumovax.

By chemically coupling a protein to the polysaccharide vaccine, the response
is better, but although these vaccines have been developed for children,
nobody has marketed them for CLL patients.

Even so responses to protein vaccines in CLL is poor. Dr Jurlander has
looked at this and found that it could be improved by taking ranitidine during the
vaccination period.

Ranitidine is a drug that blocks the H2 receptor for histamine. This is the
receptor that sends a signal to stomach cells to make acid. When the receptor
is blocked the body responds by making more histamine. Histamine improves the
immune response. There are trials going at the present time giving histamine
with IL-2 to improve the immune response against melanoma.

Dr Jurlander found that adding ranitidine to vaccination with a protein
conjugated haemophilus vaccine doubled the response rate. A recent review
recommends using ranitidine with vaccination. I passed this on to you all, but at
the time I had not read the Jurlander paper as I do not have internet access to
Leukemia, the journal that it was published in. I had to go into the hospital
library to read it. An immune response takes about 2 weeks to work, and this
was the period that I recommended. However, now that I have read the paper,
I see that Dr Jurlander used 300mg twice daily for 90 days, starting on the
day of vaccination. There was no explanation of why he decided on 90 days. He
took blood samples in days 45 and 90, so perhaps it was as arbitrary as that.
In fact most of the responses had taken place by day 45.

So, if you want to follow Dr Jurlander's recipe that is what you must do.

It won't do to take any old antacid, like lansoprazole, omeprazole,
esomeprazole, pantoprazole, or rabeprazole, it must be an H2 receptor antagonist like
cimetidine, ranitidine, famotidine or nizatidine.

Tetanus vaccination.

You should certainly have the vaccination. Whether you will respond to it is unknown. What is known is that you certainly won't respond if you don't have it.

It reminds me of the vicar who prayed earnestly to win the lottery so that he could repair the church roof. After months of failure he cursed God for His indifference. "What sort of God are you? You can't even manipulate a few numbers."

A voice came from heaven, "Look, meet me half way. Buy a ticket!"