Patients who have undergone a hematopoietic stem cell transplant (HSCT) for a hematological cancer usually lose the immunity they had acquired through vaccination. Although guidelines exist for vaccinating immunocompromised transplant recipients, many patients go unvaccinated or do not complete the series of vaccinations. An ongoing initiative at The University of Texas MD Anderson Cancer Center is using a multipronged approach to improve rates of vaccination after HSCT.
The underlying disease, radiation therapy and chemotherapy conditioning regimens, the transplant itself, and immunosuppressive drugs taken after the transplant all contribute to the loss of previously acquired immunity in patients who have undergone autologous or allogeneic HSCT. “It’s standard practice to revaccinate these patients with standard childhood vaccines, the so-called baby shots,” said Ella Ariza-Heredia, M.D., an assistant professor in the Department of Infectious Diseases, Infection Control, and Employee Health.
For various reasons, however, not all patients receive the recommended vaccines after HSCT. In some patients, vaccination is withheld or delayed intentionally, usually due to graft-versus-host disease treatment with certain drugs, such as corticosteroids or the anti-CD20 antibody rituximab. But a minority of patients who would benefit from post-HSCT vaccines do not receive them because of breakdowns in communication among clinicians or between clinicians and patients.
Dr. Ariza-Heredia is part of an effort to ensure that MD Anderson patients who have undergone HSCT receive the necessary vaccines. This joint endeavor by the Department of Stem Cell Transplantation and Cellular Therapy and the Department of Infectious Diseases, Infection Control, and Employee Health includes internal quality improvement initiatives, patient education programs, and improvements in communication between MD Anderson and referring physicians.
Steps to ensure vaccination
The first step in MD Anderson’s program to improve vaccination rates among HSCT patients was to adapt and streamline international and Infectious Diseases Society of America guidelines for post-HSCT vaccination into an internal standard operating procedures document (see table). This effort was led by clinical pharmacy services manager Alison Gulbis, Pharm.D., under the direction of Richard Champlin, M.D., a professor in and chair of the Department of Stem Cell Transplantation and Cellular Therapy. The streamlined vaccination schedule makes compliance easier for patients who receive their first round of vaccines at MD Anderson and then return to their primary care physicians for follow-up care.
Various tools are used to help patients and their community providers comply with vaccination schedules. For example, each patient is given an immunization tracking card that shows when the patient’s vaccinations are due. Face-to-face communication, however, remains the best tool. Nurses in MD Anderson’s Department of Stem Cell Transplantation and Cellular Therapy, in an effort spearheaded by Karen Stolar, A.P.N., have increased their efforts to educate patients and their families about the importance of completing the vaccine series.
“Some patients may not understand the importance of completing their vaccine series, and others simply forget because they are overwhelmed with new information,” Dr. Ariza-Heredia said. “I can see why vaccination can get lost in translation.” She added that a key component in the conversation between clinicians and patients and caregivers is to remind family members to remain current on their vaccinations so that they do not expose the immunocompromised patient to an infectious disease.
In addition, Dr. Ariza-Heredia said, “We realized that we needed to improve communication between the transplant teams and our patients’ primary care physicians. For the past 2 years, we’ve been doing this by hosting seminars for physicians, nurses, and physician assistants about posttransplant vaccination guidelines.”
Continuity of care, not just for vaccination but for all aspects of care, is essential for patients who have undergone HSCT. When a patient returns to his or her referring physician, MD Anderson physicians consult with the referring physician to discuss appropriate follow-up care, including the vaccination schedule. MD Anderson’s new electronic health record also helps by providing alerts when the patient’s next vaccination is due, and these notifications are sent to referring physicians through the EpicCare Link tool at myMDAnderson for Physicians.
“Community physicians need to be aware of the posttransplant vaccination recommendations because these providers are usually the ones who make sure the patients complete their vaccinations, and we want to be there forthem if difficult decisions or questions arise,” Dr. Ariza-Heredia said.
Improvements in compliance
Dr. Ariza-Heredia is seeing improvement in post-HSCT vaccination compliance in her daily practice. “At least once a week I get a phone call from a provider about vaccinating their posttransplant patients or about the importance of having this discussion with their patients to make sure the patients and the family members are protected,” she said.
To quantify the improvement they have observed, Dr. Ariza-Heredia and her colleagues conducted a retrospective analysis of the percentage of MD Anderson patients who began their vaccine series after HSCT. Of the patients who underwent HSCT in 2013–2014, 62% received their first vaccine dose around 6 months after HSCT. This represented an improvement of more than 20% from previous years and was a higher rate than other institutions have reported.
“We were doing a good job with vaccination, but we weren’t as good as we wanted to be; so we got better,” Dr. Ariza-Heredia said. “And we’re continuing to improve. It is important for us to consider not only the cancer treatment but also the prevention of infection. I think the relationship we have with our patients—the trust patients have in MD Anderson—gives us the opportunity to promote that culture of prevention.”
For more information about communication between MD Anderson and referring physicians, contact Dr. Ella Ariza-Heredia at 713-792-6830, visit myMDAnderson for Physicians, email firstname.lastname@example.org, or call 713-792-2202 or 877-632-6789 and select option 1.
OncoLog, July 2016, Volume 61, Issue 6