Vaccination Recommendations for Multiple Myeloma Patients Undergoing Chemotherapy
Patients with multiple myeloma should receive all age-appropriate inactivated vaccines ideally 2-4 weeks before starting chemotherapy, with complete revaccination 6-12 months after autologous stem cell transplantation if applicable, while live vaccines must be deferred until at least 24 months post-transplant in the absence of immunosuppression. 1, 2
Pre-Chemotherapy Vaccination Strategy
Timing and General Approach
- Administer all inactivated vaccines at least 2 weeks before chemotherapy initiation to optimize immune response 1
- The 2-4 week window before treatment allows for adequate antibody development while the immune system remains relatively intact 2
- Nonlive vaccines can still be given during chemotherapy if the pre-treatment window is missed, though response may be suboptimal 2
Priority Vaccines Before Chemotherapy
High-Priority Inactivated Vaccines:
- Pneumococcal vaccination: Administer PCV13 (or PCV15/PCV20) first, followed by PPSV23 at least 8 weeks later 1
- Influenza vaccine (injectable, inactivated): Give annually, ideally before flu season 1, 2
- COVID-19 vaccine: Complete primary series and boosters per current CDC recommendations 2, 3
- Hepatitis B vaccine: Three-dose series over 6 months if indicated 1
- Recombinant zoster vaccine (Shingrix): Two doses, 2-6 months apart, preferred over live zoster vaccine 1
Additional Risk-Based Vaccines:
- Hepatitis A if clinically indicated 1
- Meningococcal conjugate vaccine for high-risk patients 1
- Tdap/Td for tetanus-diphtheria-pertussis protection 2
Critical Caveat on Vaccine Response
Patients with active, uncontrolled myeloma or those already on immunosuppressive therapy will have significantly impaired vaccine responses 1, 4. The antibody response is particularly poor in patients with advanced disease stage 5. Despite suboptimal responses, vaccination is still recommended as even partial protection is beneficial 2.
Post-Autologous Stem Cell Transplant Revaccination
Timing Framework
Complete revaccination should begin 6-12 months after autologous transplant to restore vaccine-induced immunity that was lost during conditioning chemotherapy 1, 2
Accelerated Schedule for Select Vaccines:
- COVID-19, influenza, and pneumococcal vaccines may be administered as early as 3 months post-transplant given the high risk of these infections 2
- Recombinant zoster vaccine can be given 50-70 days after autologous transplant 1
Standard Inactivated Vaccine Schedule (6-12 months post-transplant):
- Pneumococcal series: PCV13 followed by PPSV23 at ≥12 months 1
- Hepatitis A: 2 doses over 6-12 months 1
- Hepatitis B: 3 doses over 6-12 months 1
- Meningococcal conjugate: 1-2 doses 1
- Inactivated polio: 3 doses 1
- HPV vaccine: 3 doses for patients up to age 26 (consider up to age 45) 1
Live Vaccines Post-Transplant
Live vaccines must be deferred until at least 24 months after transplant and only administered if there is no active graft-versus-host disease (GVHD) or ongoing immunosuppression 1, 2
- MMR vaccine: 1-2 doses if seronegative for measles, mumps, or rubella 1
- Varicella vaccine: 1 dose if seronegative 1
- Live zoster vaccine: Generally not recommended; use recombinant vaccine instead 1
Evidence from a safety study showed that MMR and live zoster vaccines were well-tolerated in myeloma patients on maintenance lenalidomide or bortezomib at a median of 25 months post-transplant, with no vaccine-strain rashes or serious adverse events 6. However, recombinant zoster vaccine remains the preferred option due to superior safety profile 1.
Special Considerations for Novel Therapies
CAR-T Therapy (CD19 or BCMA-directed)
- COVID-19 and influenza vaccines: No sooner than 3 months after CAR-T completion 2
- All other nonlive vaccines: No sooner than 6 months after CAR-T completion 2
- Expect attenuated responses due to B-cell depletion 2
B-Cell Depleting Therapy (e.g., Daratumumab, Isatuximab)
- Revaccination for COVID-19 only: No sooner than 6 months after completion of treatment 2
- Patients on daratumumab show similar vaccination responses compared to non-daratumumab therapy 1
Maintenance Therapy Considerations
- Patients on lenalidomide maintenance may have enhanced antibody responses due to immunostimulatory effects, though data are conflicting 1
- Vaccination can proceed during maintenance therapy 1
Household and Close Contact Vaccination
All household members and close contacts should be up to date on age-appropriate vaccinations, with particular emphasis on: 1, 2
- Annual influenza vaccination
- Pneumococcal vaccination for those ≥65 years
- COVID-19 vaccination and boosters
- MMR if immunity is uncertain (healthcare workers especially) 1
Important caveat: Live vaccines (except MMR) carry a small risk of transmission to immunocompromised patients; contacts should be counseled about this risk 1.
Monitoring and Practical Considerations
When Vaccine Response May Be Particularly Poor:
- Uncontrolled/active disease 1, 3
- Multiple prior lines of therapy 3
- Concurrent CD38 antibody or BCMA-directed therapy 3
- Hypogammaglobulinemia or B-cell dysfunction 2
Despite poor expected responses, long-term survivors with persistent B-cell dysfunction or hypogammaglobulinemia should still receive recommended nonlive vaccines as even partial immunity provides some protection 2.
Vaccination During Active Chemotherapy
If the pre-treatment window was missed, inactivated vaccines can be administered during chemotherapy, immunotherapy, hormonal treatment, radiation, or after surgery 2. However, vaccination upon achievement of best response (3-6 months after chemotherapy completion) yields better immune responses 1.
Postponement Criteria
Vaccination may be postponed for patients receiving >20 mg of prednisone daily due to significant immunosuppression 1.