Inactivated Vaccines Are Safe in Rheumatic Disease


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A substantial body of medical literature attests that inactivated vaccines are both safe and immunogenic in those with rheumatic disease.6 However, live attenuated vaccines are not recommended in this population.10 

According to a literature search undertaken to support European League Against Rheumatism (EULAR) evidence-based recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD), vaccinated patients with AIIRD do not experience more vaccination-related harms than unvaccinated patients with AIIRD, although the authors noted that the studies examined were underpowered and inconclusive.11

Community Rheumatologists Can Help Improve Vaccination Rates

Dr McKinnon stated that rheumatologists in the community can play a part in improving vaccine uptake. “One key step is education of both rheumatologist and their patients,” he stated.

“Strategies that include quality improvement projects can help to achieve higher rates of vaccination. As indicated in our paper, increased administration of vaccinations can be promoted by appropriate provider education and training. Another initiative that could be undertaken would be to review and update all adult recommended vaccinations prior to initiation of immunosuppressive therapy, as recommended by both ACIP [Advisory Committee on Immunization Practices] and ACR [American College of Rheumatology], and renewed yearly, similar to the current practice of tuberculosis screening with the use of biologic therapies. Yearly evaluation of vaccination needs, including influenza, pneumococcal, and tetanus-diphtheria vaccines is also needed and could be incorporated into routine clinic visits.” 

Dr McKinnon’s suggestions are in line with evidence-based guidelines from EULAR and ACR, which recommend that vaccination status be assessed in the initial workup of those with rheumatic disease.12,13

According to Dr McKinnon, several outstanding research needs remain pertinent to the uptake of vaccination in patients with rheumatic disease, including identifying a better surrogate marker of vaccine efficacy in those undergoing immunosuppressive therapy.

“This is true for several vaccines and remains an issue as well for some vaccines in immunocompetent patients,” he stated. 

There remains a need for research on the educational, social, and other barriers preventing the improvement of vaccination rates and for evaluation of different vaccination strategies, including higher doses, repeat vaccination doses, timing of vaccinations, and timing of vaccinations between dosing of biologic agents, to improve vaccine response and efficacy.

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References

1. Mok CC, Kwok CL, Ho LY, Chan PT, Yip SF. Life expectancy, standardized mortality ratios, and causes of death in six rheumatic diseases in Hong Kong, China. Arthritis Rheum. 2011;63(5):1182-1189.

2. Naz SM, Symmons DPM. Mortality in established rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2007;21(5):871-883.

3. Hmamouchi I, Winthrop K, Launay O, Dougados M. Low rate of influenza and pneumococcal vaccine coverage in rheumatoid arthritis: data from the international COMORA cohort. Vaccine. 2015;33(12):1446-1452.

4. Winthrop KL. Infections and biologic therapy in rheumatoid arthritis: our changing understanding of risk and prevention. Rheum Dis Clin North Am. 2012;38(4):727-745.

5. Curtis JR, Arora T, Narongroeknawin P, et al. The delivery of evidence-based preventive care for older Americans with arthritis. Arthritis Res Ther. 2010;12(4):R144.

6. Papadopoulou D, Tsoulas C, Tragiannidis A, Sipsas NV. Role of vaccinations and prophylaxis in rheumatic diseases. Best Pract Res Clin Rheumatol. 2015;29(2):306-318.

7. McMahan ZH, Bingham CO 3rd. Effects of biological and non-biological immunomodulatory therapies on the immunogenicity of vaccines in patients with rheumatic diseases. Arthritis Res Ther. 2014;16(6):506.

8. Hua C, Barnetche T, Combe B, Morel J. Effect of methotrexate, anti-tumor necrosis factor α, and rituximab on the immune response to influenza and pneumococcal vaccines in patients with rheumatoid arthritis: a systematic review and meta-analysis. Arthritis Care Res (Hoboken). 2014;66(7):1016-1026.

9. McKinnon JE, Maksimowicz-McKinnon K. Autoimmune disease and vaccination: impact on infectious disease prevention and a look at future applications. Transl Res. 2016;167(1):46-60.

10. Bijl M, Agmon-Levin N, Dayer JM, Israeli E, Gatto M, Shoenfeld Y. Vaccination of patients with auto-immune inflammatory rheumatic diseases requires careful benefit-risk assessment. Autoimmun Rev. 2012;11(8):572-576.

11. van Assen S, Elkayam O, Agmon-Levin N, et al. Vaccination in adult patients with auto-immune inflammatory rheumatic diseases: a systematic literature review for the European League Against Rheumatism evidence-based recommendations for vaccination in adult patients with auto-immune inflammatory rheumatic diseases. Autoimmun Rev. 2011;10(6):341-352.

12. van Assen S, Agmon-Levin N, Elkayam O, et al. EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2011;70(3):414-422.

13. Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2016;68(1):1-26.