BLOG: Preparing HSCT, CAR-T recipients for the respiratory viral season
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Key takeaways:
- HSCT or CAR-T recipients are more likely to develop severe symptoms from respiratory viruses.
- Clinicians should emphasize the importance of these patients using preventive measures and risk-reducing strategies.
This blog post provides answers to important questions about the upcoming respiratory viral seasons.
It also offers advice for what clinicians can tell at-risk patients, including those who have undergone hematopoietic stem cell transplantation or chimeric antigen receptor T-cell therapy.
What is expected this respiratory viral season?
With the anticipated increase last year in all three major respiratory viruses — influenza, respiratory syncytial virus (RSV) and SARS CoV-2 — the term “triple epidemic," sometimes called “tripledemic,” was coined.
Following last year’s “tripledemic,” preparations for the upcoming respiratory viral season are underway at most institutions.
According to CDC’s Center for Forecasting and Outbreak Analytics, this year's hospitalizations from influenza, RSV and COVID-19 could be like last year's.
Patients undergoing HSCT or CAR T-cell therapy are more likely than the general population to experience severe sickness caused by community-acquired respiratory viruses, with increased rates of morbidity and death.
Consequently, it is vital to safeguard them using all available preventive measures to minimize potential for harm.
What can we tell our patients?
The main message is that our patients now have more tools than ever.
We have vaccinations accessible for all three significant respiratory viruses for the first time in our nation’s history.
There has been a recent increase in COVID-19 and RSV cases, with influenza shortly behind. The time to vaccinate them is now.
If eligible, all patients undergoing HSCT or CAR T-cell therapy should receive the revised COVID-19 vaccine and the flu shot.
As recommended by their transplant centers, patients aged older than 60 years should receive the RSV vaccine.
Families and caregivers of immunocompromised patients also are strongly advised to obtain the recommended vaccinations — flu, COVID-19 and RSV, if eligible — to protect their loved ones.
Although HSCT and CAR-T recipients are at high risk for severe illness and long-term complications from respiratory viruses, they also are less likely to respond to vaccines. These patients may require additional doses or different immunization schedules to optimize responses.
What is new for vaccines this season?
In addition to prevention, vaccination is an essential defense against severe respiratory virus infection among HSCT and CAR-T recipients.
For adult HSCT and CAR-T recipients, passive protection against the winter respiratory viruses is not currently attainable through monoclonal antibodies.
There are two RSV vaccines for this season.
For adults aged 60 years or older, the overall efficacy of both vaccines for preventing lower respiratory tract infection exceeded 80%.
HSCT/CAR-T recipients who stand to benefit from a vaccine aimed at preventing lower respiratory tract infection fall into the highest risk category; however, none of these clinical trials included HCT recipients or other immunosuppressed patients.
RSV vaccine can be considered for HSCT recipients aged older than 60 years old who are eligible for routine vaccination after HSCT. Vaccination outside this group may not be covered by insurance.
Dedicated studies of HSCT recipients are needed to evaluate RSV vaccine immunogenicity, clinical efficacy and the optimal vaccination schedule. The impact of vaccination could be more apparent preventing RSV infection among family members or health care workers who care for immunocompromised patients.
The updated COVID-19 vaccines by Pfizer/BioNTech and Moderna are designed to protect against the more recent circulating viral strains — including EG.5 and BA.2.86 — in addition to XBB.1.5. All immunocompromised patients should get at least one shot of either of these vaccines as directed by their transplant centers.
For the 2023-2024 flu season, the viral makeup of the vaccine is comparable to that of the preceding season. All immunocompromised individuals can get age-appropriate inactivated (IIV4s) or recombinant (RIV4) influenza vaccines under the guidance of their transplant center, preferably before HSCT or CAR-T if timing allows.
Co-administration of COVID-19 and influenza vaccine at different injection sites is safe. CDC guidance states that all three can be given simultaneously but that patients likely will experience increased reactogenicity, such as fevers, headache, swelling or pain at the injection site. Discussing the timing of administration with patients is essential to managing adverse events and the best response from the vaccine.
What should we tell patients to do if they get sick?
All three respiratory viruses exhibit indistinguishable influenza-like illness (ILI) signs and symptoms. If ILI symptoms are recorded, the patient should be checked for the diagnosis using a nucleic amplification test of the nasopharynx, especially if they are in the early post-HSCT or post-CAR T-cell therapy phase.
There is no FDA-approved at-home testing to identify the three respiratory viruses.
SARS-CoV-2 and influenza respiratory tract infections are treatable with antiviral treatments. Early directed antiviral treatment should be started to prevent the severity of the illness based on the risk for progression of infection to the lower respiratory tract; however, institutional standards vary regarding the choice of antiviral drugs.
RSV is an FDA-approved therapy for hepatitis C infection and is used off-label for treating RSV. Society treatment guidelines and additional resources are listed in the references for further guidance.
How else can immunocompromised patients protect themselves?
Prevention is the key.
Patients should get vaccinated if eligible and exercise caution by avoiding sick contact as much as possible.
Masking also can help reduce infection during times of heightened community transmission.
Patients should be mindful of local trends and seek medical help immediately if they develop signs and symptoms suggestive of respiratory tract infection.
References:
- CDC. Respiratory disease season outlook — Summary. Available at: https://www.cdc.gov/respiratory-viruses/whats-new/2023-2024-season-outlook.html.
- CDC. COVID data tracker. Available at: https://covid.cdc.gov/covid-data-tracker/#trends_select_testpositivity_00.
- CDC: Weekly U.S. influenza surveillance report. Available at: https://www.cdc.gov/flu/weekly/index.htm.
- CDC. Protect yourself from COVID-19, Flu and RSV. Available at: https://www.cdc.gov/respiratory-viruses/index.html.
- CDC. Frequently asked questions about RSV vaccine for adults. Available at: https://www.cdc.gov/vaccines/vpd/rsv/hcp/older-adults-faqs.html.
- CDC. Recommended updated (2023-2024 formula) COVID-19 vaccines for people who are moderately or severely immunocompromised. Available at: https://www.cdc.gov/vaccines/covid-19/downloads/COVID19-vaccination-recommendations-immunocompromised.pdf.
- CDC. Summary: Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2023-24. Available at: https://www.cdc.gov/flu/professionals/acip/summary/summary-recommendations.htm#immunocompromised.
- CDC, IDSA. Considerations for coadministering COVID, flu and/or RSV vaccines this fall. Available at: https://www.idsociety.org/covid-19-real-time-learning-network/vaccines/considerations-for-coadministering-covid-flu-andor-rsv-vaccines-this-fall/#/+/0/publishedDate_na_dt/desc/.
- Chaer FE, et al. Transplant Cell Ther. 2023;doi:10.1016/j.jtct.2023.09.018.
- Dioverti V, et al. Transplant Cell Ther. 2022;doi:10.1016/j.jtct.2022.09.002.
- Hause AM, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.22241.
- Izikson R, et al. Lancet Respir Med. 2022;doi:10.1016/S2213-2600(21)00557-9.
- Janssen C, et al. Hum Vaccin Immunother. 2022;doi:10.1080/21645515.2022.2131166.
- Lazarus R, et al. Lancet. 2021;doi:10.1016/S0140-6736(21)02329-1.
- Mammas IN, et al. Exp Ther Med. 2023;doi:10.3892/etm.2023.12033.
- Rubin LG, et al. Clin Infect Dis. 2014;doi:10.1093/cid/cit816.
- Waghmare A, et al. Blood. 2016;doi:10.1182/blood-2016-01-634873.
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