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The COVID-19 vaccine and Waldenstrom’s macroglobulinaemia (WM)

covid vaccine
We’ve worked with our Waldenstrom's Macroglobulinaemia specialists Dr Dima El-Sharkawi (Consultant Haematologist at Royal Marsden Hospital) and Dr Shirley D’Sa (lead WM clinician at UCLH) to answer some of your top questions about what the COVID-19 vaccine is, and what it means for you.

Page last updated: 11 January 2021

At the start of December, the UK was the first country in the world to approve a vaccine for COVID-19, bringing hope to many that the lockdown and accompanying restrictions on daily life may soon come to an end.

We know, though, that many people still have questions about the vaccine, and what it means for them as someone affected by WM.

Whether you have the vaccine or not is ultimately your choice, but we hope the information below will help you make an informed decision.

Background

How does a vaccine work?

The aim of a vaccine is to expose a person to a protein or part of the pathogen (e.g. virus or bacteria) such that it will provoke the person’s immune system to create immune cells that will recognise the pathogen. If the vaccinated person is ever exposed to the pathogen in the future, the primed immune system will be able to kill or block the virus/bacteria thereby preventing the disease from forming.

Why vaccinate against infections?

This may seem like an obvious question but it is nonetheless important as this can have an impact on the vaccination strategy that the government will employ and how we will assess the impact and efficacy of the vaccination programme with time.

Vaccinations tend to be developed for infections that can be spread easily between people, and can cause significant morbidity (health problems) and mortality (death).

  • Personal protection
    Vaccinations of people can offer personal protection to the person who has been vaccinated, preventing the disease from developing in that person. Some vaccinations offer long term protection and therefore only need to be given once, and some offer more short term protection and so the vaccine may need to be repeated in the future to maintain protection. (As of yet, we do not know whether the vaccines against SARS-CoV-2 will offer short or long term protection).
  • Population protection/ Herd immunity
    Herd immunity is when enough people in a population are immune from an infection (either through having recovered and developing natural immunity or vaccination) that it protects everyone in the population even those who are not vaccinated as the infection cannot “take hold” within the population and the rate with which the infection can spread (the R rate) remains low.

    Here you will find a really good visual explanation of herd immunity by Dr Hannah Fry.

Initial aims of the vaccine against SARS-CoV-2 (COVID-19) and order of priority of vaccination delivery

The aims of the vaccination programme to begin with is to provide personal protection for those most vulnerable to the complications of COVID-19, and therefore whilst the programme is being rolled out, the order of priority of who receives the vaccine is based on this.  At the time of writing the JCVI (Joint Committee on Vaccination and Immunisation), an independent body who advise the government issued a statement regarding the order of priority for individuals to be vaccinated which was as follows:

  1. Residents in a care home for older adults and their carers
  2. All those 80 years of age and over. Frontline health and social care workers
  3. All those 75 years of age and over
  4. All those 70 years of age and over. Clinically extremely vulnerable individuals*
  5. All those 65 years of age and over
  6. All individuals aged 16 years to 64 years with underlying health conditions which put them at higher risk of serious disease and mortality
  7. All those 60 years of age and over
  8. All those 55 years of age and over
  9. All those 50 years of age and over

* Clinically extremely vulnerable individuals are described here. This advice on vaccination does not include pregnant women and those under the age of 16 years.

Reference: Joint Committee on Vaccination and Immunisation: advice on priority groups for COVID-19 vaccination 30 December 2020

(This information was issued on 2 December 2020 and may be subject to change).

Thus by definition, all people with WM will fall into at least category 4, those older than 75 will fall into a higher priority group on the basis of their age. At time of writing, there is no plan to prioritise household contacts of clinically extremely vulnerable individuals to receive the vaccine any earlier.

What is the difference between the vaccines?

There are over 300 different vaccines being developed against SARS-CoV-2 (COVID-19). For a vaccine to be able to be used in the UK, it needs to be approved for use by the UK medical regulatory authority, MHRA. The MHRA will review the data and approve its use based on safety and efficacy seen in the trials. Despite the rapid approval of this vaccine by the MHRA, none of the regulatory steps have been missed out. Rather than wait for all the data on safety and effectiveness to amass before reviewing the vaccine, the MHRA has been conducting a rolling review of the data as and when they become available from ongoing studies. This has enabled rapid approval.

There are three companies that have reported the data from their vaccines so far and it should be noted that none of these are live vaccines. Whilst the MHRA have been able to review the data from the clinical trials conducted by these companies, the only information that is publicly available are the press releases with minimal information. Pfizer-BioNTech has been reported to be up to 95% effective, Moderna 94% effective and Oxford AstraZeneca between 62-90% effective depending on dose given. All the trials have been conducted in thousands of people although it is unclear at this point how many had underlying health problems. At time of writing, one vaccine by Pfizer-BioNTech has been approved for use in the UK, and as of 30 December 2020 the AstraZeneca-Oxford vaccine has also been approved.

  • Messenger RNA (mRNA) vaccine: (i.e. the genetic code for part of the virus): The mRNA enters cells and allows a virus protein to be made by affected  cells, which in turn stimulate immune cells to specifically target that protein.

    The advantages to this are that it is quicker and cheaper to make this vaccine than other types and could in theory be modified more easily should the COVID virus change/ mutate with time. The disadvantage is that it needs to be stored at very low temperatures and thus is not easy to transport and store.

    The Moderna and Pfizer vaccines use this technology.

  • Viral vector vaccine: a weakened harmless virus is modified to include the gene that codes for one of the coronavirus protein (the spike protein), when this is given to a person, the virus enters cells allowing the protein to be made and the person’s immune system to create immune cells specifically targeting that protein. 

    The Oxford-AstraZeneca vaccine uses this technology.

Other technologies to make vaccines against COVID-19 are also being used but they are earlier in the trial development.

AstraZeneca are also running trials looking at the effectiveness of “antibody cocktails” with the aim of providing short term immunity against SARS-CoV-2 for patients who have a lowered immune system and so for whom vaccinations may be less effective. We await the results of these trials with particular interest.

Which vaccine is better for people with WM?

At present, each company developing vaccines is conducting trials just looking at the effectiveness of their vaccine, and so no head-to-head trials comparing the efficacy are being conducted. We do not know which vaccine will prove to be the most effective or safest for the population in general or people with WM. Under these unusual circumstances, it will be a case of which vaccine is available first.

Will the vaccine be effective for people with WM?

No vaccination is 100% effective in anybody. Not everyone has the same risk of getting infected by the virus in the first place. This is influenced by the state of the immune system as well as precautions taken against exposure. The effectiveness of a vaccine is measured in trials by counting the number of COVID-19 infections in people who received the real vaccine vs those who received a placebo.

Measuring antibody levels after vaccination can be carried out, but we will not know for many months whether this translates into immunity as the levels may decline over time, and this measurement does not take account of other immune mechanisms such as the T cell response.

There is a theoretical possibility and extrapolating from our knowledge of other vaccinations, that these vaccines may not be as effective for people with WM. This is because the immune system is altered by having WM and by the treatments given for WM and so you may not be able to mount a very good immune response when the vaccination is given. This is not a reason to decline the vaccination, as it may still provide some protection, but equally you should still be cautious and try and minimise your risk of exposure to the virus. In time, as an increasing proportion of the population is vaccinated, the prevalence of the virus will fall, reducing the need to minimise contact.

Is the vaccine safe (for people with WM)?

As previously stated, despite the rapid approval of the Pfizer vaccine, rigorous testing has already occurred. Data from preclinical studies and continuing trials of the vaccine involving 43,000 people to date has been reviewed. This includes manufacturing and quality control assessments, and independent tests on batches of the vaccine by scientists. Data are reviewed daily and collated to ensure that any new information is investigated. If any concerns arise during this careful follow up, the MHRA would issue warnings to avoid certain groups or withdraw the vaccine altogether.

There is no reason to suspect that people with WM are at any greater risk than average from these vaccines. Nor should they interfere with any existing medication.

We recommend that if you have any concerns - including about allergic reactions - to speak with your clinician before getting the vaccine.

I am due another vaccination, e.g. flu vaccine. Will this affect the COVID-19 vaccine?

There are no data at present about the co-administration of these vaccines with others. The advice from Public Health England is pragmatic and suggests that if possible you should space the vaccinations by at least 14 days in case you have a reaction to one, then you can tell which one it was. If you have not yet had the flu vaccine this year, it would be sensible to consider getting this as soon as possible, before the COVID-19 vaccine programme is started.

I've already had COVID-19, should I still get the vaccine?

In short: yes. The COVID-19 vaccination should be offered to you regardless of whether you have already contracted the COVID-19 virus. You should not be required to have an antibody test before you are vaccinated.

However, anyone currently infected with COVID-19 should wait to get vaccinated until after their illness has resolved and after they have met the criteria to discontinue isolation. You’re currently recommended to wait 28 days from the onset of your infection. Anyone with COVID-19 symptoms or a positive test result must stay at home for the full isolation period. This is because they could pass it on to others, even if they don’t have symptoms.

Additionally, current evidence suggests that reinfection with the virus that causes COVID-19 is uncommon in the 90 days after initial infection. Therefore, people with a recent infection may delay vaccination until the end of that 90 day period if desired.

What about shielding and social distancing?

Social distancing measures, including shielding for the clinically extremely vulnerable, is something that we all have under our control and is our number one tool against COVID-19. Even after having the vaccine, it's vitally important to stick to the government guidance for your region to best protect yourself and those around you. You can find out more about the latest guidance here.

So, should I have the vaccine?

We are still living through uncertain times - normal practice and behaviours are still some time away. However, the development of vaccines against SARS-CoV-2 provides the first real opportunity for protection against COVID-19. Ultimately every person will have to make a personal decision about receiving the vaccine when it is offered to them. We hope this information is useful in the decision-making process.

Even after receiving the vaccine, life will not instantly return to normal as the logistics on vaccination on such a massive scale mean that it will take weeks to months for herd immunity to be generated and confirmed as being robust over time. In the meantime, continued precautions regarding unnecessary exposure are important.

Watch this space! We will provide further updates as they become available.

Have any questions? Call or email us for support and information.

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