Tuesday, November 11, 2008

"I've had enough of reading things by neurotic, psychotic,pig headed politicians" John Lennon

"All I want is the truth
Just give some me some truth"

John Lennon

Below is an editied version of the email I sent to Dr. Forman when I mentioned to him my concern about the ACIP recommendation concerning the zoster vaccine, during my office visit yesterday.

If you are a CLL patient, be prepared to be astonished by the advice your government is giving to the medical community.

Dear Dr. Forman,

In the process of reviewing a paper for publication of herpes zoster, I came across this possibly dangerous statement in italics below from "The Prevention of herpes zoster. Recommendations of the Advisory Committee on Immunization Practices (ACIP)" (http://www.guideline.gov/summary/summary.aspx?doc_id=12633&nbr=6541&ss=6&xl=999). You may also read the full recommendations at the web address above.

Immunocompromised Persons

Zoster vaccine should not be administered to persons with primary or acquired immunodeficiency including:

• Persons with leukemia, lymphomas, or other malignant neoplasms affecting the bone marrow or lymphatic system. However, patients whose leukemia is in remission and who have not received chemotherapy (e.g., alkylating drugs or antimetabolites) or radiation for at least 3 months can receive zoster vaccine.

As we know, patients with CLL should never have live vaccines. I hope a letter to the authors from a PCP would make an impact. I will do what I can to have the language changed in regards to CLL.  I have started a search for source material on the safety of live vaccines in CLL. I would appreciate your advice and support and any reference material in this effort.

The decision about the offering the HZ vaccine is often made by a primary care provider who would not question the guidelines of ACIP who work under the umbrella of the CDC. Indeed the paper I am reviewing has a case studies that recommends HZ vaccine in a patient with CLL in remission.  If I didn't have personal experience with CLL,  I would not have questioned the recommendation.

Thank you so much,


Your patient and colleague,

Brian Koffman MDCM FCFP, DAAFP, MS Ed

So now it looks like I am not fighting city hall, but the feds. First, I will try to align all my allies in the heme/onc community, and get appropriate references to back up my battle. This guideline must be changed.

If you are not a CLL patient you might be wondering why this has so upset me. A live vaccine might be very very dangerous for anyone with CLL, at any stage of disease. CLL impairs one's immunity, even when in deep remission and a live vaccine can cause havoc when the defences are down.

Let me share this with you.

On the other hand, patients with CLL should be regarded as immunodeficient as far as vaccination with live attenuated organisms is concerned and these should be avoided.

Hamblin, D. and Hamblin, T. J. The immunodeficiency of chronic lymphocytic leukaemia British Medical Bulletin 2008; 87: 49–62 A.

Below are quotes from two CLL experts who many of my leukemia friends know too well.

First, patients with CLL should never have live vaccines.“ Dr T. J. Hamblin, Professor of Immunohaematology Southampton 1986 to present. Honorary Consultant Haematologist Kings College Hospital, London, 2004-present.

CLL patients should not get the shingles vaccine as it is a live virus.” Dr. Richard Furman, assistant professor, Division of Hematology and Oncology, Weill Medical College at Cornell University, New York, NY.

I will keep you posted, though the change will come slowly, it surely will come.

To quote Rabbi Tarfon

It is not your part to finish the task, yet you are not free to desist from it. 

Pirke Avoth 2:16

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Anonymous Anonymous said...

Hi Brian

Clearly there is a problem here, but perhaps it is the nature of the Zoster virus that makes it an exception to the Hamblin et al rule about no live vaccines.

Chances are you and I and about 99% of humans have been exposed to chickenpox at sometime in our childhood. This exposure could mean that we have Zoster virus in our bodies already. While the virus we have is still 'alive' it is in a latent state living in nerve ganglia cells.

It is this latent virus that causes shingles. You can NOT get shingles from the live vaccine. It must be contracted as chickenpox (varicella zoster virus) and then go through years of latency before it can become reactivated as shingles.

What triggers this reactivation is immune system deficiency or perhaps psychological stress.

Since the vaccine can not 'give' a patient shingles it could add a load to the immune system. The effects on CLL patients of the Zoster vaccine is virtually unknown.

In this case I think caution is advised as the CLL experts point out, until a clinical study can resolve this.


November 12, 2008 at 7:36 AM  

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