Immunogenicity of the Currently Recommended Pneumococcal Vaccination Schedule in Patients With Chronic Lymphocytic Leukaemia.
Conditions: Pneumococcal Infections, Chronic Lymphocytic Leukemia, Vaccine-Preventable Diseases, Invasive Pneumococcal Disease, Recurrent Isolated
Sponsor: Hannah Garcia Garrido

PNEUMO-CLL study  
 
Protocol Date: 01-06-2020 
Page 1/6 
Pneumo-CLL study: Immunogenicity of the Currently 
Recommended Pneumococcal Vaccination Schedule in 
Patients with Chronic Lymphocytic Leukaemia. 
 
PROTOCOL 
 
 
 
Principal Investigator: 
K. de Heer 
Co-investigator: 
 
H. Garcia Garrido 
 
Writing committee:  
A. Goorhuis 
 
 
 
 
H. Otten 
 
 
 
 
H. Visser 
 
 
 
 
F. de Boer 
 
 
 
 
J. Droogendijk 
 
 
 
 
I. Verpoorte 
 
 
 
 
D. Issa 
 
 
 
 
R. te Raa 
 
 
 
 
R. van der Griend 
 
 
 
 
H. van der Straaten 
 
 
 
 
M-D. Levin 
 
 
 
 
S. Kersting 
 
 
 
 
A. Kater 
 
 
 

PNEUMO-CLL study  
 
Protocol Date: 01-06-2020 
Page 2/6 
1. Introduction 
 
Patients with chronic lymphocytic leukaemia (CLL) are at increased risk of both invasive 
pneumococcal disease (IPD) and community acquired pneumonia (CAP) caused by Streptococcus 
pneumoniae [1-3]. Therefore, international guidelines recommend pneumococcal vaccination for all 
CLL patients, preferably before initiation of treatment. The recommended vaccination schedule 
consists of Prevenar13®, a 13-valent pneumococcal conjugated vaccine (PCV13) followed 2 
months later by Pneumovax23, a 23-valent polysaccharide vaccine (PPSV23) [4, 5]. 
The immunological efficacy of this sequential vaccination schedule in CLL patients is unknown. 
Previous studies have only investigated responses to either PCV13 or PPSV23 alone (Table 1) [6-
15].  Responses to PPSV23 alone are poor in CLL patients [7, 9, 10, 14, 15]. Responses to the 7-
valent pneumococcal conjugated vaccine (PCV7) or PCV13 are higher compared to responses to 
PPSV23, but lower compared to responses in healthy individuals [6, 8, 15]. More advanced disease 
stage and lower baseline IgG negatively influence responses to vaccination (Table 1) [6, 14, 15].  
 
 
Table 1 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
 
  
Study
Year
N (final 
analysis)
Population
Vaccination schedule Serologic respone definition
Response rate
Factors associated with response
A) Studies investigating schedules containing conjugated vaccines (PCV7/PCV13)
Sinisalo et al 
(8)
2007
73
n=49 CLL (15% 
steroids, 22% chemo, 
80% Binet A, median 
disease duration 2 
years);    n=24 healthy
PCV7 only
≥ 2 fold IgG rise AND serotype 
specific IgG ≥ 0.35 mcg/l for at least 
6/7 PCV7 serotypes
24% CLL; 71% controls
Less advanced disease; no past or 
ongoing chemotherapy; normal IgG.
Paiarski et al 
(6)
2014
39
Treatment naive CLL 
(n=24); Healthy (n=15)
PCV13 only
≥2 fold Total anti-pneumococcal IgG
58.3% CLL; 100% 
controls
Lower stage of CLL, higher total IgG
Andrick et al 
(11)
2017
8
n=4 CLL + ibrutinib; n= 
4 CLL - ibrutinib
PCV13 only
≥2-fold increase in 3 or more out of 
13 serotypes 
Ibrutinib 0%;                   
No Ibrutinib 100%
X
Svensson et 
al (15)
2018
128
Treatment naive CLL 
patients
PCV7 versus PPSV23 
(RCT)
Serotype specific OPA titers to 
PCV13 serotypes > Lowel Limit of 
Quantification (OPA titers = 
interpolated reciprocal serum 
dilution resulting in complement-
mediated killing of 50% of the assay 
bacteria) 
PCV13: 32% ; PPSV23 
21%
Less advanced disease; higher total 
l IgG 
Lindström et 
al (13)
2018
24
CLL, follow-up study 
of Sinisalo 2007
PCV7 5 years before
Serotype specific IgG ≥ 0.35 mcg/l 
(per serotype)
For individual 
serotypes 29-71% of 
the patients were still 
protected 
X
Lindström et 
al (12)
2019
28
CLL (n=20); healthy 
controls (n=8), follow-
up study of Sinisalo 
2007
PCV7 and 5 years later 
PPSV23
Serotype specific IgG  for all PCV7 
serotypes AND PPSV23 serotype 5 
and 7 
10-15%
Healthy controls had higher 
responses to all serotypes
Hartkamp et 
al (14)
2001
24
57% Rai 0-1; 28% prior 
chemothrapy; median 
disease duration >36 
months
PPSV23
Protection: 2/3 serotypes 20% above 
cut-off based on reference adult 
hyperimmune plasma pool; 
Response: >2 fold increase + 
protection (defintition above)
Response: 22%         
Protection: improved 
from 38% to 50% after 
vaccine;                       
Higher disease stage + lower 
baseline IgG; prior chemotherapy 
negatively impacted responses
Sinisalo et al 
(7)
2001
27
n=14 Binet A, n=8 
Binet B n=9 Binet C), 
median disease 
duration 3 years. 
PPSV23 
A significant proportionate change 
in total anti-pneumcoccal IgG (no cut-
off value given)
0%
X
van der 
Velden et al 
(9)
2007
49
CLL >50% RAI 0; 20% 
previous 
chemotherapy
PPSV23  (with or 
without ranitidine)
 Response =>4 fold increase in IgG to 
3 serotypes; Protection: ≥0,35 
mcg/ml 
Response: 1% 
response;         
'Protection' increased 
from 45%-59%
Ranitidine did not generate better 
responses
Safdar et al 
(10)
2008
32
87% had previous 
chemotehrapy and 
73% anti-CD20 
PPSV23 (n=7); PPSV23 
+ G-CSF injections 
(n=25)
 ≥2-fold IgG rise and level 
>0.5mcg/ml for all 6 measured 
seorypes
 0% (0-17% per 
individual serotype)
G-CSF did not generate better 
responses
B) Studies investigating PPSV23 only 

PNEUMO-CLL study  
 
Protocol Date: 01-06-2020 
Page 3/6 
2. Objective 
 
The aim of this observational cohort study is to assess the immunogenicity of the currently 
recommended vaccination schedule of PCV13 followed by PPSV23 in CLL patients.  
 
3. Study design 
 
As part of routine care, all adult CLL patients naïve to pneumococcal vaccination and cared for in 
the participating centers receive one dose of Prevenar13® followed by one dose of Pneumovax23® 
2 months later. According to the current local standard of care for immunosuppressed individuals, 
the response to vaccination is assessed by measuring pneumococcal antibody levels before and 4-8 
weeks after vaccination [16, 17]. In this non-interventional cohort study we will ask informed 
consent to all vaccinated CLL patients to collect their clinical data and laboratory results for study 
purposes.  
 
4. Inclusion criteria 
 
All adult CLL patients  
 naïve to pneumococcal vaccination, 
 having received one dose of Prevenar13®, 
 followed by one dose of Pneumovax23® 2 months later, 
 in whom pneumococcal antibody levels before and 4-8 weeks after vaccination are 
measured, and  
 in whom a complete data collection is possible. 
 
 
 

PNEUMO-CLL study  
 
Protocol Date: 01-06-2020 
Page 4/6 
5. Data collection 
 
After we obtain informed consent clinical data will be collected according to a standardized 
electronic case report form (Castor EDC). Variables included in the case report form are:  
 sex 
 smoking behaviour 
 age at the moment of the PCV vaccine administration 
 comorbidities (charlson comorbitiy index) 
 before vaccination (as determined in the 6 weeks prior to vaccination) 
◦ 
Rai stage (I/II/III) 
◦ 
past or ongoing chemotherapy 
◦ 
ongoing steroid treatment 
◦ 
past or ongoing therapy with a monoclonal anti-CD20 antibody (and date of last 
infusion) 
◦ 
total IgG level 
◦ 
lymphocyte count, haemoglobin and platelet level 
 pre-vaccination pneumococcal IgG levels 
 post-vaccination pneumococcal IgG levels 
 date of PCV and PPSV23 vaccine administration 
 date of antibody measurements 
 
Laboratory methods and definitions 
Serotype-specific pneumococcal immunoglobulin G (IgG) concentrations to 5 pneumococcal 
serotypes shared across both vaccines (6B, 9V, 14, 19F, 23F) and 4 serotypes unique to PPSV23 (8, 
15B, 20, 33F) will be determined in the immunology laboratory of the UMC Utrecht. A validated 
multiplex immunoassay will be used (Luminex® technology). Serologic response will be defined as 
a ≥4-fold increase in serotype specific anti-pneumococcal IgG for ≥70% of measured. Serologic 
protection will be defined as an antibody concentration ≥1.3 mcg/ml for ≥70% of all measured 
serotypes, according to the definition of the American Academy of Allergy, Asthma & Immunology 
[18]. In addition, because most previous studies (Table 1) used the WHO cut-off for protection in 
infants (≥0.35 mcg/ml) we will also analyse our data by the infant correlate of protection to be able 
to compare our results with previous studies [19]. 

PNEUMO-CLL study  
 
Protocol Date: 01-06-2020 
Page 5/6 
6. Data Analysis 
 
The primary outcome of the study is serologic response rate (SRR) after vaccination. Secondary 
outcomes of interest are serologic protection rates (SPR) after vaccination analysed by the 2 most 
widely accepted serologic cut-offs described above, geometric mean antibody concentrations before 
and after vaccination, and factors associated with response to vaccination, such as age, treatment 
status and disease stage. To this end, we will perform a multivariable logistic regression analysis, 
starting with all previously mentioned clinical variables of interest and using a stepwise backward 
selection method based on p-value <0.1. For data analysis, we will use IBM SPSS version 24.0 
(Chicago, Illinois) software. We will apply an α significance level of 0.05. Means and standard 
deviations will be presented for normally distributed data, and medians and interquartile ranges for 
non-normally distributed data. The χ2 test will be used for dichotomous variables and the Student t 
test or Mann-Whitney U test for normally or non-normally distributed continuous variables, 
respectively. The Wilcoxon signed-rank test will be used to compare median pre- and post-
vaccination antibody concentrations.  
 
7. Ethical considerations and privacy 
 
For this non-interventional study, participants are not exposed to additional study procedures. 
Vaccination and assessment of vaccination responses are according to local standard of care. A 
waiver for medical ethical assessment has been issued by the Medical Ethical Committee of the 
Amsterdam UMC-Location AMC. Informed consent will be asked of each individual patient for use 
of their data for research purposes. A data protection impact analysis will be performed in 
collaboration with privacy advisors of all participating hospitals.  
 

PNEUMO-CLL study  
 
Protocol Date: 01-06-2020 
Page 6/6 
8. References 
 
1. 
Backhaus, E., et al., Epidemiology of invasive pneumococcal infections: manifestations, incidence 
and case fatality rate correlated to age, gender and risk factors. BMC Infect Dis, 2016. 16: p. 367. 
2. 
Williams, A.M., et al., Analysis of the risk of infection in patients with chronic lymphocytic leukemia 
in the era of novel therapies. Leuk Lymphoma, 2018. 59(3): p. 625-632. 
3. 
Lindstrom, V., et al., Invasive pneumococcal disease in patients with haematological malignancies 
before routine use of conjugate vaccines in Finland. Infect Dis (Lond), 2016. 48(5): p. 399-402. 
4. 
Mikulska, M., et al., Vaccination of patients with haematological malignancies who did not have 
transplantations: guidelines from the 2017 European Conference on Infections in Leukaemia (ECIL 
7). Lancet Infect Dis, 2019. 19(6): p. e188-e199. 
5. 
Rubin, L.G., et al., 2013 IDSA clinical practice guideline for vaccination of the immunocompromised 
host. Clin Infect Dis, 2014. 58(3): p. 309-18. 
6. 
Pasiarski, M., et al., Antibody and plasmablast response to 13-valent pneumococcal conjugate 
vaccine in chronic lymphocytic leukemia patients--preliminary report. PLoS One, 2014. 9(12): p. 
e114966. 
7. 
Sinisalo, M., et al., Response to vaccination against different types of antigens in patients with 
chronic lymphocytic leukaemia. Br J Haematol, 2001. 114(1): p. 107-10. 
8. 
Sinisalo, M., et al., Antibody response to 7-valent conjugated pneumococcal vaccine in patients with 
chronic lymphocytic leukaemia. Vaccine, 2007. 26(1): p. 82-7. 
9. 
Van der Velden, A.M., et al., The effect of ranitidine on antibody responses to polysaccharide 
vaccines in patients with B-cell chronic lymphocytic leukaemia. Eur J Haematol, 2007. 79(1): p. 47-
52. 
10. 
Safdar, A., et al., Multiple-dose granulocyte-macrophage-colony-stimulating factor plus 23-valent 
polysaccharide pneumococcal vaccine in patients with chronic lymphocytic leukemia: a prospective, 
randomized trial of safety and immunogenicity. Cancer, 2008. 113(2): p. 383-7. 
11. 
Andrick, B., et al., Lack of adequate pneumococcal vaccination response in chronic lymphocytic 
leukaemia patients receiving ibrutinib. Br J Haematol, 2018. 182(5): p. 712-714. 
12. 
Lindstrom, V., et al., Antibody response to the 23-valent pneumococcal polysaccharide vaccine after 
conjugate vaccine in patients with chronic lymphocytic leukemia. Hum Vaccin Immunother, 2019. 
15(12): p. 2910-2913. 
13. 
Lindstrom, V., et al., Antibody persistence after pneumococcal conjugate vaccination in patients with 
chronic lymphocytic leukemia. Hum Vaccin Immunother, 2018. 14(6): p. 1471-1474. 
14. 
Hartkamp, A., et al., Antibody responses to pneumococcal and haemophilus vaccinations in patients 
with B-cell chronic lymphocytic leukaemia. Vaccine, 2001. 19(13-14): p. 1671-7. 
15. 
Svensson, T., et al., Pneumococcal conjugate vaccine triggers a better immune response than 
pneumococcal polysaccharide vaccine in patients with chronic lymphocytic leukemia A randomized 
study by the Swedish CLL group. Vaccine, 2018. 36(25): p. 3701-3707. 
16. 
AMC. http://www2.hematologie-amc.nl/MATCH-RVP-009_revaccinatie 2018. 
17. 
RIVM, Landelijke adviezen voor vaccinatie bij chronisch inflammatoire aandoeningen. 2018. 
18. 
Orange, J.S., et al., Use and interpretation of diagnostic vaccination in primary immunodeficiency: a 
working group report of the Basic and Clinical Immunology Interest Section of the American 
Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol, 2012. 130(3 Suppl): p. S1-24. 
19. 
Jodar, L., et al., Serological criteria for evaluation and licensure of new pneumococcal conjugate 
vaccine formulations for use in infants. Vaccine, 2003. 21(23): p. 3265-72.