What Rheumatologists Need to Know About Vaccines in Rheumatic Diseases

Vaccination and immunization play an important part in the management of adult patients with autoimmune inflammatory rheumatic diseases (AIIRD) who are at increased risk for infections as a result of their underlying condition, associated comorbidities, and immunosuppressive therapy, including glucocorticoids and disease-modifying antirheumatic drugs (DMARDs).¹ Children with rheumatic diseases are also at greater risk for infection; however, the appropriateness of vaccination in these patients has been debated by numerous experts.²

The World Health Organization (WHO) established World Immunization Week 2020 to encourage vaccination on a global level. This year, the theme of Immunization Week, held between April 24 and 30, 2020, is VaccinesWork for All, with a goal of encouraging recognition of the importance of vaccination in disease prevention.³

With the coronavirus disease 2019 (COVID-19) pandemic at large, the WHO has recognized the need for a safe and effective vaccine to control the spread of the infection among all populations.⁴ However, factors related to low vaccination rates among patients with rheumatic disease often include concerns about efficacy, immunogenicity, and the safety of vaccines.^1,5

Rheumatologists are recommended to have a working knowledge of vaccines for patients with rheumatic disease, and immunization must be individualized based on a shared decision-making process between the healthcare provider and patient.

At the American College of Rheumatology (ACR) State-of-the Art Clinical Symposium 2019, Brian Schwartz, MD, from the University of California, San Francisco, noted, “When a rheumatologist is about to start a patient on treatment, it’s a good idea for patients and their physicians to consider vaccinations and think ahead, possibly holding off on starting a medication to ensure the vaccine can be effective.”⁶ 

Top 3 Things Rheumatologists Need to Know About Vaccinations and Rheumatic Disease

1.      Flu vaccines are generally safe and effective for patients with rheumatic disease, with a potential contraindication being anaphylaxis.

Compared with the general population, patients with AIIRD have increased mortality and morbidity because of vaccine-preventable illnesses such as influenza.⁷ These patients should receive the seasonal influenza vaccine annually, except in cases where contraindications, including hypersensitivity to vaccine components, are present. These patients are also advised to receive the flu vaccine before starting immunosuppressive therapy or if they are immunosuppressed.⁸

Recurrence of reactions in patients who experience vaccine-related adverse events, including Guillain-Barré syndrome, is rare, and the risk of morbidity and mortality is greater with the flu; therefore, vaccination is recommended for these patients. Patients with egg allergies may receive an egg-free vaccine for active immunization against influenza A and B.⁹

All children, including those with rheumatic disease, are recommended to receive annual vaccination against influenza. According to a review, no difference in local and systemic tolerability of the flu vaccine was seen among healthy children vs those with rheumatic diseases.²

2.      Patients with rheumatic diseases, barring a few subgroups, may receive live vaccines.

Live vaccines may be safely administered in adult patients receiving prednisone <20 mg/d, methotrexate <0.4 mg/kg/wk, azathioprine 3 mg/kg/d, or mercaptopurine <1.5 mg/kg/d, according to the Advisory Committee on Immunization Practices (ACIP).^1,9,10 In accordance with guidance from ACIP and ACR, live vaccines, including measles and zoster, should be administered to patients ≥4 weeks before starting immunosuppressive therapy, except in circumstances where risks outweigh vaccination benefits.⁸ In his ACR address, Dr Schwartz also mentioned consideration of the inactivated zoster vaccine for immunosuppressed patients with rheumatologic conditions.⁶

Patients with rheumatic diseases should be advised to avoid close contact with family members or others who have been vaccinated with live vaccines; however, this should not deter any individual with or without immunosuppression from receiving the recommended vaccines.⁶

Live vaccines are typically contraindicated in pregnant women with rheumatic diseases because the mild infection they produce may affect the fetus.⁵ According to European League Against Rheumatism (EULAR) recommendations, live-attenuated vaccines should also be avoided for 6 months after delivery in mothers who have been treated with biologics during the second half of their pregnancy.¹

3.      Patients With AIIRD should receive repeated pneumococcal vaccines.

Patients with AIIRD who may be starting or are currently receiving immunosuppressive therapy are strongly recommended to receive the 13-valent pneumococcal vaccine (PCV13) to protect against Streptococcus pneumoniae and then the 23-valent pneumococcal polysaccharide vaccine (PPSV23) after ≥8 weeks.⁸ In her blog posting, Kathryn H. Dao, MD, associate professor in the Division of Rheumatology at UT Southwestern Medical Center in Dallas, Texas, noted that the timing of pneumococcal vaccination is crucial. If patients with rheumatic disease receive PPSV23 first, PCV13 must be administered ≥1 year later, whereas if PCV13 is given first, PPSV23 may be administered only ≥2 months later.⁹

Both PCV13 and PPSV23 must ideally be administered ≥2 weeks before initiation of immunosuppressive therapy; however, if vaccination is not possible before starting immunosuppressive medications, the pneumococcal vaccines should be administered as soon as possible and/or when immunosuppression is low. With regard to booster doses for PPSV23, recommendations vary among rheumatology providers, but revaccination with PCV13 is not required.⁸

Among children with rheumatic disease, pneumococcal vaccination is strongly recommended because infections with S pneumoniae may be severe, especially in children undergoing treatment with antitumor necrosis factor agents.²

References

1. Furer V, Rondaan C, Heijstek MW, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2020;79(1):39-52.

2. Dell’Era L, Esposito S, Corona F, Principi N. Vaccination of children and adolescents with rheumatic diseases. Rheumatology (Oxford). 2011;50(8):1358-1365.

3. World Health Organization. World Immunization Week 2020. Accessed April 26, 2020. https://www.who.int/news-room/events/detail/2020/04/24/default-calendar/world-immunization-week-2020

4. World Health Organization. Update on WHO solidarity trial – accelerating a safe and effective COVID-19 vaccine. Accessed April 25, 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-trial-accelerating-a-safe-and-effective-covid-19-vaccine

5. Hospital for Special Surgery. Vaccinations and rheumatic disease. Updated January 10, 2011. Accessed April 26, 2020. https://www.hss.edu/conditions_vaccinations-rheumatic-disease.asp

6. Collins TR. Vaccines & rheumatology patients. The Rheumatologist website. Published June 12, 2019. Accessed April 26, 2020. https://www.the-rheumatologist.org/article/vaccines-rheumatology-patients/?singlepage=1

7. Westra J, Rondaan C, van Assen S, Bijl M. Vaccination of patients with autoimmune inflammatory rheumatic diseases. Nat Rev Rheum. 2015;11:135-145.

8. Kotton CN, Winthrop KL. Immunizations in autoimmune inflammatory rheumatic disease in adults. UpToDate website. Updated February 11, 2020. Accessed April 26, 2020. https://www.uptodate.com/contents/immunizations-in-autoimmune-inflammatory-rheumatic-disease-in-adults/print

9. Dao KH. Top 5 things rheumatologists should know about vaccines. RheumNow website. Published May 6, 2015. Accessed April 28, 2020.  http://rheumnow.com/blog/top-5-things-rheumatologists-should-know-about-vaccines

10. Centers for Disease Control and Prevention. Vaccine recommendations and guidelines of the ACIP. Updated March 30, 2020. Accessed April 26, 2020. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html