Those who have rheumatic disease have an elevated risk for infection and a greater risk that infection will have a more serious outcome. In those with rheumatoid arthritis and other rheumatic disease, infection is the most frequent cause of excess mortality.1,2 The greater risk for infection in patients with rheumatic disease is related to both the disease process and the effects of therapies commonly used to treat these disorders, including immunosuppressive agents and corticosteroids.3,4 

Yet despite decades of research on the disproportionate impact of infection on those with rheumatic disease, patients in this population are less likely than those without rheumatic disease to undergo routine vaccination against preventable diseases. 

An analysis of patient records data from the Centers for Medicare & Medicaid Chronic Conditions Data Warehouse showed that only approximately one-third of patients with arthritis received pneumococcal vaccination, and only approximately 20% of patients with arthritis received an annual influenza vaccination. Among patients with rheumatoid or psoriatic arthritis, 17.3% and 15.6%, respectively, did not receive an influenza vaccination at all.5

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Reasons for Insufficient Vaccine Uptake

The lack of optimal vaccine uptake in patients with rheumatic disease is likely related to open questions about whether immune responses to vaccines are adequate in those receiving immunotherapy and whether vaccinations might trigger flares of existing disease or cause new autoimmune disorders to develop.6 

Effects of immunosuppressive agents on humoral response have been noted. Those treated with rituximab in particular have experienced diminished immune responses to both influenza and pneumococcal vaccine.7 Methotrexate reduces humoral response to pneumococcal vaccination and may blunt the response to influenza vaccination.8 

Concerns about flares stem from the possible danger of stimulating the immune system (via vaccination) of those in whom the immune system is already stimulated. The literature on immunization-induced flare of underlying disease and the development of de novo rheumatic disease consists primarily of case reports, and evidence for these effects has not been supported by controlled trials, by postmarket monitoring, or by reviews of adverse effects for influenza, pneumococcus, human papillomavirus, and other vaccinations.9

In an email interview with Rheumatology Advisor, John McKinnon, MD, an infectious disease specialist at Detroit’s Henry Ford Health System and the author of a recent review published in Translational Research on autoimmune disease and vaccination,9 said that significant misconceptions and lack of knowledge about the safety of vaccines among both patients and practitioners lead to lower vaccination rates in those with autoimmune diseases. 

“Both primary care providers and rheumatologists have concerns for vaccine side effects and or safety in immunosuppressed patients that are unsubstantiated. Physicians may not be cognizant of or [may] unintentionally neglect updating either live and killed vaccines prior to initiation of immunosuppressive therapy, leading to patients remaining at risk for preventable illnesses,” he stated.