Tag: stem cell transplant

Does the FluMist Vaccine Shed?

Anti-vaccine folks like to talk a lot about shedding.

Where do they get the idea that vaccines shed?

Well, there is the fact that some live vaccines, like the rotavirus and oral polio vaccine, do actually shed.

Does the FluMist Vaccine Shed?

Remember, shedding occurs when an infectious agent, typically a virus, can be found in urine, stool, or other bodily secretions. Shedding is not specific to vaccines though. Shedding occurs very commonly after natural infections too, which is one reason they are so hard to control.

So does the Flumist vaccine shed?

Yes, it does, and it isn’t a secret.

There is actually a warning about shedding and Flumist – to avoid contact with severely immunosuppressed persons (e.g., hematopoietic stem cell transplant recipients in a protected enviornment) for seven days after vaccination because of the theoretical risk that their severe immunosuppression might allow the weakened flu strain to somehow cause disease.

This warning obviously doesn’t apply to the great majority of people though.

And it shouldn’t be surprising that it sheds, after all, it is a live virus vaccine that is squirted in your nose!

Why isn’t it usually a problem?

Flumist contains attenuated viral strains of the flu that are temperature-sensitive, so even if you did get infected with the weakened flu strains from Flumist via shedding, they wouldn’t cause disease.

Another way to think about it is that the folks who actually get the Flumist vaccine don’t get the flu, so why would you get the flu if you were simply exposed to the vaccine virus by shedding?

Shedding from the Flumist vaccine doesn't cause disease.
Anti-vaccine folks are sharing this table like they uncovered some secret, but it is important to understand that shedding from the Flumist vaccine doesn’t cause disease. And this table is in package insert for Flumist!

The real concern with shedding is when it leads to folks actually getting sick.

Trying to scare folks about Flumist shedding is just like when they talk about the MMR vaccine, pushing the idea that the rubella vaccine virus might shed into breast milk or measles vaccine virus into urine. Either might happen, but since it won’t cause infection and disease, it certainly isn’t a reason to skip or delay your child’s vaccines.

What to Know About Shedding and Flumist

The Flumist vaccine does indeed shed, but unless you are going to have contact with someone who is severely immunocompromised in a protected environment, this type of shedding isn’t going to get anyone sick and isn’t a reason to avoid this vaccine.

More on Shedding and Flumist

Vaccines While Immunosuppressed

It seems to be a big surprise to many folks, but kids can get most vaccines when they are immunosuppressed. In fact, they sometimes get extra some extra vaccines, like Pneumovax, because the  “incidence or severity of some vaccine-preventable diseases is higher in persons with altered immunocompetence.”

They should also get all of their vaccines if they are around someone who is immunosuppressed.

Surprised?

Vaccines While Immunosuppressed

Which vaccines your kids can get while they are immunosuppressed is going to depend greatly on the reason why they are  immunosuppressed.

Are they getting chemotherapy?

Did they just get a stem cell transplant?

Were they born with a specific immunodeficiency, like X-linked agammaglobulinemia, selective IgA deficiency, severe combined immunodeficiency, or chronic granulomatous disease?

Whatever the reason, they likely won’t get a medical exemption to skip all of their vaccines.

“Killed vaccines will not cause infection in immunodeficient or any other children. The fear of increased community-acquired vaccine-preventable diseases should lead to adherence to and completion of recommended immunization schedules in the community to reinforce herd immunity, such that all vaccine-preventable diseases become exceedingly rare.”

Recommendations for live viral and bacterial vaccines in immunodeficient patients and their close contacts

In most cases, immunocompromised kids can get all inactivated vaccines. It is only live vaccines that could pose a problem. Even then, it depends on the specific immunodeficiency as to whether avoiding live vaccines is necessary.

For example, after chemotherapy and a stem cell transplant, kids can usually get live vaccines.

Your doctors can review the latest guidelines to come up with a safe vaccination plan for your child with an immune system problem. If necessary, consultation with an infectious diseases or immunology specialist can also be helpful.

Don’t overlook other causes of possible immunosuppression when getting vaccinated, like taking daily oral steroids for more than two weeks, certain biologic immune modulators, or other medications like methotrexate, azathioprine, 6-mercaptopurine.

“Limited evidence indicates that inactivated vaccines generally have the same safety profile in immunocompromised patients as in immunocompetent individuals. However, the magnitude, breadth, and persistence of the immune response to vaccination may be reduced or absent in immunocompromised persons.”

2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host

And keep in mind that just because they can and should get vaccinated, it doesn’t mean that their vaccines are going to work as well as in someone who isn’t immunocompromised.

That’s why herd immunity is so important for these kids.

Vaccines for Close Contacts of Immunocompromised People

What about people who come into contacts with kids and adults who are immunocompromised?

Can they get vaccines?

“Close contacts of patients with compromised immunity should not receive live oral poliovirus vaccine because they might shed the virus and infect a patient with compromised immunity. Close contacts can receive other standard vaccines because viral shedding is unlikely and these pose little risk of infection to a subject with compromised immunity.”

Recommendations for live viral and bacterial vaccines in immunodeficient patients and their close contacts

Yes, close contacts can get vaccinated, especially since we don’t use the oral polio vaccine in the United States anymore.

There are some exceptions for the smallpox vaccine, which few people get, and Flumist, but only in very specific situations, including a recent hematopoietic stem cell transplant.

Johns Hopkins Medicine, which includes the Johns Hopkins University School of Medicine and the The Johns Hopkins Hospital and Health System went out of their way to correct this anti-vaccine misinformation.
Johns Hopkins Medicine, which includes the Johns Hopkins University School of Medicine and the The Johns Hopkins Hospital and Health System went out of their way to correct this anti-vaccine misinformation.

Worried about shedding?

You should be worried about getting a vaccine-preventable disease and giving it to those around you with immune system problems. That’s the real risk!

This is the modern anti-vaccine movement - taking an immoral stand against vaccines and putting sick kids at risk for life-threatening disease.
This is the modern anti-vaccine movement – scaring parents and taking an immoral stand against vaccines and putting sick kids at risk for life-threatening disease.

And no, you are not being selfish to expect those around you to get vaccinated.

Vaccines are safe and necessary – for all of us.

More on Vaccines While Immunosuppressed

Vaccines After Cancer and Chemotherapy

Most people know that children being treated for cancer have a suppressed immune system and are at extra risk for vaccine-preventable diseases.

Many children with cancer and other medical conditions benefit from herd immunity.
Many children with cancer and other medical conditions benefit from herd immunity. (CC BY 2.0)

That’s one of the reasons that it is important for everyone to be vaccinated, so that herd immunity levels of protection can protect those who can’t get vaccines.

Vaccines After Cancer and Chemotherapy

But what happens after they complete their cancer treatments?

“The interval until immune reconstitution varies with the intensity and type of immunosuppressive therapy, radiation therapy, underlying disease, and other factors. Therefore, often it is not possible to make a definitive recommendation for an interval after cessation of immunosuppressive therapy when inactivated vaccines can be administered effectively or when live-virus vaccines can be administered safely and effectively.”

Red Book on Immunization in Immunocompromised Children

After they complete therapy for cancer, whether it is chemotherapy or a bone marrow transplant, many children need to get extra vaccines.

In the UK, for example, 6 months after completing “standard antileukemia chemotherapy,” children get a booster dose of DTaP, IPV, Hib, MenC, and MMR.

Why just a single booster dose?

Because most kids can continue to get non-live vaccines on schedule while they are getting standard chemotherapy. They get a booster dose when they finish chemotherapy because those vaccine doses they got while receiving treatment might not be as effective as usual and typically don’t count as valid doses.

Of course, if they were missing any doses, then they might need extra doses to catch up too.

“Three months after cancer chemotherapy, patients should be vaccinated with inactivated vaccines and the live vaccines for varicella; measles, mumps, and rubella; and measles, mumps, and rubella-varicella according to the CDC annual schedule that is routinely indicated for immunocompetent persons.”

2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host

In contrast to those getting standard chemotherapy, if treatment involved a hematopoietic stem cell transplant (HSCT), then these children are essentially revaccinated:

  • beginning at 6 months after the HSCT, they should get 3 doses of DTaP if they are less than 7-years-old vs a dose of Tdap and 2 doses of Td if they are already 7-years-old
  • beginning at 3-6 months after the HSCT, they should get 3 doses of Prevnar
  • beginning at 6-12 months after the HSCT, they should get 3 doses of Hib
  • beginning at 6-12 months after the HSCT, they should get 3 doses of hepatitis B, followed by postvaccination anti-HBs titer testing
  • beginning at 6-12 months after the HSCT, they should get 3 doses of IPV
  • beginning at 6-12 months after the HSCT, they should get 2 doses of a meningocococcal vaccine (if they are already 11 to 18 years old)
  • beginning at 6-12 months after the HSCT, they should get 3 doses of  HPV vaccine (if they are already 11 to 26 years old)
  • beginning at 12 months after the HSCT, one dose of the Pneumovax vaccine
  • beginning at 24 months after the HSCT, two doses of MMR
  • beginning at 24 months after the HSCT, two doses of the chicken pox vaccine
  • a yearly flu shot

Why not just check titers instead of repeating all of those vaccines?

“protective” concentrations or titers in this population may not be as valid as in healthy children, leaving open the question regarding what levels to use as the basis for revaccination. Furthermore, there are some vaccines for which no serological correlate of protection exists (e.g., pertussis) or for which, in routine practice, it is too difficult to have levels measured (e.g., polio).

Soonie R. Patel et al. on Revaccination of Children after Completion of Standard Chemotherapy for Acute Leukemia

In Canada, they used to check titers at 1, 3, and 5 years after the end of chemotherapy and just vaccinate when titers dropped, but they switched to giving all kids a booster dose, as it works better.

What will your child’s immunization look like after completing treatment for cancer?

Although the specific recommendations will come from your child’s treatment team, they will likely look something like the guidelines included here.

What to Know About Vaccines After Cancer and Chemotherapy

Kids often have to get revaccinated, or at least get booster doses of their vaccines, after completing treatment for cancer.

More on Vaccines After Cancer and Chemotherapy