Updated 2019 EULAR Recommendations for Vaccination in Adults With Autoimmune Inflammatory Rheumatic Diseases

doctor preparing injection
doctor preparing injection
A steering committee put together by EULAR has updated recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases.

According to new evidence and an expert consensus, a steering committee put together by the European League Against Rheumatism (EULAR) released updated recommendations for managing vaccinations in adults with autoimmune inflammatory rheumatic diseases (AIIRD). The report was published in Annals of the Rheumatic Diseases.

Investigators performed 4 systematic reviews of literature focused on the prevalence of vaccine-preventable infections in adults with AIIRD; the efficacy, immunogenicity, and safety of vaccines in this patient population; the effect of antirheumatic drugs on vaccination response; and the effect of vaccination of household members of patients with AIIRD. The steering committee devised related questions, elicited expert opinions, and reached a consensus on 6 overarching principles and 9 recommendations.

Overarching Principles

Rheumatology teams should assess patients with AIIRD yearly to determine vaccination status and indications for further vaccination. Individualized vaccination programs should be explained by rheumatology teams to their patients, thereby providing a basis for shared decision making; the primary care physician, the rheumatology team, and the patient should jointly implement the program.

Patients with AIIRD should preferably be vaccinated during quiescent disease, and vaccines should be administered before immunosuppression, especially B cell depleting therapy.

Patients with AIIRD who are being treated with systemic glucocorticoids and drug-modifying antirheumatic drugs (DMARDs) should receive nonlive vaccines; live-attenuated vaccines may be considered with caution.

Recommendations for Influenza Vaccination

EULAR recommends that physicians strongly consider the influenza vaccination for the majority of patients with AIIRD. From the 2011 guidelines, this recommendation changed “all” to “majority” of patients, as not all patients with AIIRD are considered immunosuppressed, and therefore, are not at increased risk for influenza-related morbidity.

Recommendations for Pneumococcal Vaccination

EULAR also recommends that physicians strongly consider pneumococcal vaccination for the majority of patients with AIIRD because of increased risk for noninvasive and invasive pneumococcal disease. In patients with cryopyrin-associated periodic syndrome, the risk for treatment-related adverse events should be carefully considered before vaccination.

Recommendations for Tetanus Vaccination

Patients with AIIRD should receive toxoid tetanus vaccination in accordance with tetanus recommendations for the general population. Patients treated with B cell depleting therapy should be considered for passive immunization in case of high-risk exposure to tetanus.

Recommendations for Hepatitis Vaccination

In adults with AIIRD, hepatitis A virus and hepatitis B virus (HBV) vaccinations should be administrated only to patients at risk, including those residing in or traveling to endemic countries or patients who are at increased risk for HBV exposure (eg, hospital personnel, household contacts, sexual partners with HBV).

Among patients using immunosuppressive therapies and those with rheumatoid arthritis, the hepatitis A vaccine does not provide sufficient protection, and booster or passive immunization is indicated. Booster or passive immunization with the HBV vaccine is also indicated in patients using biologic DMARDs or those who experience percutaneous exposure to HBV.

Recommendations for Herpes Zoster Vaccination

Patients with AIIRD and at increased risk for herpes zoster may be considered to receive the live-attenuated herpes zoster vaccination, preferably administered 4 weeks before initiating treatment with DMARDs. A new nonlive herpes zoster vaccine may be more efficacious and safer, especially in elderly patients (aged ≥50 years); subject to future studies, this nonlive vaccine may replace the live-attenuated vaccine recommended for patients with AIIRD.

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Recommendations for Yellow Fever Vaccination

EULAR recommends against yellow fever vaccination in patients with immunosuppression. This recommendation was updated after new but limited experience administering the yellow fever vaccine in patients with AIIRD. In patients traveling to endemic countries, physicians may consider withholding immunosuppressive therapy to allow for safe vaccination, or consider measuring serology in previously exposed patients.

Recommendations for HPV Vaccination

As indicated for the general population, EULAR recommends that patients with AIIRD receive vaccinations against human papillomavirus (HPV). According to new evidence, EULAR recommends that HPV vaccination be encouraged particularly in patients with systemic lupus erythematosus.

Recommendations for Household Members

In accordance with the guidelines of international societies, such as the Infectious Diseases Society of America, EULAR encourages immunocompetent household members of patients with AIIRD to receive inactivated and live-attenuated vaccines, according to national guidelines. However, oral polio vaccines should be avoided because of risk for transmission among household members.

Recommendations for Newborns

Since immunoglobulins cross the placenta in the third trimester, EULAR recommends avoiding live-attenuated vaccines in newborns during the first 6 months after birth if the mother was treated with biologics during the second half of pregnancy. EULAR also suggests that, when available, physicians can measure child serum levels of the biologic to guide their decision for or against live vaccination.


Furer V, Rondaan C, Heijstek MW, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases [published online August 14, 2019]. Ann Rheum Dis. doi:10.1136/annrheumdis-2019–215882