COVID Vaccine and CLL: What Patients Need to Know

Chronic lymphocytic leukemia (CLL) is a cancer of the same immune cells that normally make antibodies, so it blunts the body’s response to vaccines. COVID shots are safe for people with CLL, but they often protect less than they do in healthy people. Protection isn’t all or nothing, though. How well the vaccine works depends heavily on your treatment and timing, and extra doses can still help. Vaccinated people with CLL who catch COVID also end up in the hospital less often than unvaccinated ones.1Blood Advances. Outcomes of breakthrough COVID-19 infections in patients with hematologic malignancies

How Well the Vaccine Works in CLL

An antibody response means a blood test finds antibodies against the virus’s spike protein after vaccination. Across about 1,450 people with CLL, about 51% had antibodies after two doses.2PubMed Central. Immunogenicity of COVID-1://dx.doi.org/10.1182/bloodadvances.2021006333 Healthy adults respond almost 100% of the time.3PubMed Central. Cellular and humoral immune response to SARS-CoV-2 mRNA vaccines in patients treated with either Ibrutinib or Rituximab One dose alone gave antibodies to only about 18% of people with CLL.4PubMed Central. Immunogenicity of COVID-1://dx.doi.org/10.1182/bloodadvances.2021006333 Finishing the full series therefore matters more for you than for most people.

The gap exists because CLL cells crowd out healthy B cells, the cells that make antibodies. Many people with CLL also have low antibody levels in their blood overall, and this affects responses to other vaccines too, not just COVID. “Half respond” is a population figure, not a forecast for you. Your own odds depend mostly on your treatment, covered next.

Not making antibodies does not mean the shot did nothing. Vaccinated people with blood cancers who caught COVID were hospitalized about 31% of the time, versus about 53% of unvaccinated people.5Blood Advances. Outcomes of breakthrough COVID-19 infections in patients with hematologic malignancies The death rate was similar in both groups, about 7% to 9%.6Blood Advances. Outcomes of breakthrough COVID-19 infections in patients with hematologic malignancies So the vaccine lowers the chance of a serious hospital stay but can’t be your only protection.

How Your CLL Treatment Affects the Vaccine

These ranges come from different studies and labs, so treat them as rough odds. Ask your doctor which group you fall in, including how long ago any rituximab-type drug was given.

Anti-CD20 therapy, such as rituximab or obinutuzumab, wipes out the B cells that make antibodies.13PubMed Central. COVID-19 Vaccination Response and Its Practical Application in Patients With Chronic Lymphocytic Leukemia Those B cells have to grow back before a vaccine can work well. People treated with these drugs within the past year had about 136 times lower antibody levels.14PubMed Central. Humoral Responses Against SARS-CoV-2 and Variants of Concern After mRNA Vaccines in Patients With Non-Hodgkin Lymphoma and Chronic Lymphocytic Leukemia A booster worked much better when given 12 or more months after the last rituximab-type dose, about 23% vs 4%.15PubMed Central. Efficacy of a third BNT162b2 mRNA COVID-19 vaccine dose in patients with CLL who failed standard 2-dose vaccination

Other things lower your odds too. Low blood levels of the antibodies IgG and IgA made a booster less likely to work.16PubMed Central. Efficacy of a third BNT162b2 mRNA COVID-19 vaccine dose in patients with CLL who failed standard 2-dose vaccination Having several other health conditions raised the chance of catching COVID again.17PubMed Central. Prognostic factors associated with recurrent COVID-19 and impact of SARS-CoV-2 vaccine on patients with chronic lymphocytic leukemia

When to Get Vaccinated Around Treatment

Expert guidance says vaccines work best given at least 2 to 4 weeks before starting therapy.18CLL Society. COVID Vaccine and CLL: What Patients Need to Know If your doctor says treatment is coming, ask to get up to date first. This holds even when active disease already weakens response.19Decera Clinical Education. COVID-19 Vaccine in CLL – ClinicalThought – Lymphomas COVID

You can be vaccinated while taking a BTK inhibitor or venetoclax, though response may be lower.20CLL Society. COVID Vaccine and CLL: What Patients Need to Know COVID and flu shots should come at least 4 weeks after the latest treatment dose, and be repeated 6 months or more after therapy ends.21CLL Society. COVID Vaccine and CLL: What Patients Need to Know For rituximab-type drugs, some experts suggest waiting until 12 months after the last dose when COVID is less common locally.22Decera Clinical Education. COVID-19 Vaccine in CLL – ClinicalThought – Lymphomas COVID Antibody infusions (IVIG), which some people with CLL get, don’t change vaccine timing.23CLL Society. COVID Vaccine and CLL: What Patients Need to Know

One small study saw higher antibody levels when BTK pills were paused for about 3 weeks around a booster.24PubMed. Interruption of BTK inhibitor improves response to SARS-CoV-2 booster vaccination in patients with CLL A larger study found pausing did not improve antibody response and advises against it.25The ASCO Post. Pausing vs Continuing BTK Inhibitors at Time of COVID-19 Vaccination in Patients With CLL Don’t stop your medicine on your own; discuss it with your hematologist.

Boosters When the First Shots Didn’t Work

Among people with CLL who made no antibodies after two doses, about 24% did after a third.26PubMed Central. Efficacy of a third BNT162b2 mRNA COVID-19 vaccine dose in patients with CLL who failed standard 2-dose vaccination That rose to about 40% among people not on active treatment.27JNCCN. Can a Third Dose of COVID-19 Vaccine Produce Antibodies in Seronegative Patients With CLL? Only about 12% of people on active treatment responded.28JNCCN. Can a Third Dose of COVID-19 Vaccine Produce Antibodies in Seronegative Patients With CLL? Some studies saw no booster response in non-responders, others up to 40%.29PubMed Central. COVID-19 in Patients with Chronic Lymphocytic Leukemia: What Have We Learned?

About a third of people with CLL who had COVID caught it again, usually around 14 months later.30PubMed Central. Prognostic factors associated with recurrent COVID-19 and impact of SARS-CoV-2 vaccine on patients with chronic lymphocytic leukemia Those who had boosters went about 16 months before reinfection, versus about 9 months without.31PubMed Central. Prognostic factors associated with recurrent COVID-19 and impact of SARS-CoV-2 vaccine on patients with chronic lymphocytic leukemia In one small group, all six had antibodies after a fourth dose, versus four of six after three.32PubMed. Hybrid immunity to SARS-CoV-2 in patients with chronic lymphocytic leukemia Each new seasonal shot is another chance to build response, so follow your doctor’s advice on extra doses for immunocompromised people.

Protection Beyond Antibodies

T cells are immune cells that attack infected cells rather than making antibodies. After a booster, four of six people with CLL in one small group showed stronger T-cell activity.33Haematologica. SARS-CoV-2-specific cellular response following third COVID-19 vaccination in patients with chronic lymphocytic leukemia Extra doses also increased T cells aimed at Omicron in people with CLL.34DTU Research Database. Deciphering SARS-CoV-2 Protective Immunity in Hematological Malignancies Standard antibody tests don’t measure T cells, so a negative result may underestimate your protection.

People with CLL who had COVID and then three doses showed strong antibody and T-cell immunity, similar to healthy people.35PubMed Central. Hybrid immunity in immunocompromised patients with CLL after SARS-CoV-2 infection followed by booster mRNA vaccination Some who had failed vaccination made antibodies after a fourth dose plus infection, even on B-cell-depleting drugs.36PubMed. Hybrid immunity to SARS-CoV-2 in patients with chronic lymphocytic leukemia

Is the Vaccine Safe With CLL

In over 300 people with CLL, about 54% reported no side effects after two doses.37PubMed Central. Safety and efficacy of the BNT162b mRNA COVID-19 vaccine in patients with chronic lymphocytic leukemia All side effects reported were mild to moderate.38PubMed Central. Safety and efficacy of the BNT162b mRNA COVID-19 vaccine in patients with chronic lymphocytic leukemia The most common was a sore arm, in about 32%.39PubMed Central. Safety and efficacy of the BNT162b mRNA COVID-19 vaccine in patients with chronic lymphocytic leukemia Fever affected about 4%.40PubMed Central. Safety and efficacy of the BNT162b mRNA COVID-19 vaccine in patients with chronic lymphocytic leukemia In a study of newer versions, no serious side effects were seen; common ones were arm soreness, tiredness and cough.41CLL Society. New COVID Vaccine Boosts Cellular Response in CLL Patients Having side effects or not had no link to making antibodies.42PubMed Central. Safety and efficacy of the BNT162b mRNA COVID-19 vaccine in patients with chronic lymphocytic leukemia

Fever in someone with CLL can also mean infection, so call your doctor if it lasts beyond a day or two. Report swelling or breathing trouble promptly.

Should You Get an Antibody Test

A spike antibody test, often done a month or more after the last dose, shows whether you made antibodies.43Blood. Humoral and Cellular Immunogenicity of COVID-19 Vaccinations in Patients with CLL In one CLL group tested about 45 days after vaccination, 61% had antibodies.44Blood. Humoral and Cellular Immunogenicity of COVID-19 Vaccinations in Patients with CLL Testing too early can understate what you made.

A positive result means protection is likely but may fade. A negative one is the time to ask about extra doses and added protection. Results vary by lab, so compare them with your doctor’s guidance.

If you test right after an IVIG infusion, the result can be confusing because those infusions can carry donor antibodies, so ask how to interpret it. Ask which test your lab runs too: a spike antibody test reflects vaccination, while some other tests respond to past infection.

Other Ways to Lower Your COVID Risk

About 16.5% of people with CLL who recovered from COVID developed long COVID symptoms such as tiredness and breathlessness.45PubMed. The evolving landscape of COVID-19 and post-COVID condition in patients with chronic lymphocytic leukemia: A study by ERIC, the European research initiative on CLL It usually cleared in about 5 months.46PubMed. The evolving landscape of COVID-19 and post-COVID condition in patients with chronic lymphocytic leukemia: A study by ERIC, the European research initiative on CLL More severe infection was the main risk.47PubMed. The evolving landscape of COVID-19 and post-COVID condition in patients with chronic lymphocytic leukemia: A study by ERIC, the European research initiative on CLL

Vaccinated family members lower your exposure. Wear a mask in crowded indoor places during surges, and avoid sick contacts.

If you get sick, test as soon as symptoms start and call your hematologist the same day. Antiviral treatment works best given early.

Other vaccines respond weakly too. People on BTK pills respond to flu shots only about 7% to 26% of the time.48The ASCO Post. Lessons From Pneumococcal Vaccine Responses in Patients With CLL in an Evolving Vaccine Landscape Conjugate pneumonia vaccines work better in CLL than older plain ones, and giving them soon after diagnosis gives the best response.49PubMed Central. Influenza and Pneumococcal Vaccination in Hematological Malignancies: a Systematic Review of Efficacy, Effectiveness, and Safety

Plan flu, pneumonia and shingles shots with your doctor. The shingles vaccine can be given a month after a rituximab-type dose.50CLL Society. COVID Vaccine and CLL: What Patients Need to Know Avoid live vaccines unless your doctor approves.