Systemic lupus erythematosus (SLE) disproportionately affects women, with a peak in incidence during reproductive years,1-3 and results in a significantly higher risk of developing cardiovascular disease, cerebrovascular disease, and cancer compared with the general population.4-6 Immunosuppressive medications are frequently used to treat autoimmune rheumatic conditions, which, combined with the diseases, place individuals at a heightened risk for serious infections.7,8 Despite proven efficacy and safety in patients with chronic rheumatic diseases, vaccination rates are suboptimal, especially among patients with SLE who are affected by high rates of serious infections and related mortality.7,9,10

Highlighting the Disproportionate Burden of SLE

Profound racial/ethnic and socioeconomic disparities in adverse, often avoidable, outcomes occur in nearly all rheumatic diseases and these disparities are particularly prominent among Black individuals and those of lower socioeconomic status with SLE.11-13

Black patients with SLE are less likely than White patients to receive standard-of-care vaccine recommendations from their physicians, despite higher risks for serious infections and acute care use for vaccine-preventable illnesses.7,14,15 The disproportionate burden of current COVID-19 infections in vulnerable populations, including individuals with SLE, accentuates the importance of working to improve avoidable vaccine-preventable illnesses.13


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Rosalind Ramsey-Goldman, MD, DrPH

In SLE, profound racial/ethnic disparities have been demonstrated in care fragmentation, serious infection burden, and associated mortality, all of which disproportionately affect Black individuals compared with White individuals.7,15

Using the Chicago HealthLNK Data Repository, which includes electronic health records from 6 institutions that provide care to individuals in vulnerable neighborhoods, among patients with SLE, it was found that Black or publicly insured patients were more likely to experience care fragmentation compared with White and private insurance patients. Black vs White patients also had increased odds of infections (odds ratio [OR], 1.57; 95% CI, 1.30-1.88), after adjustment for age, sex, insurance status, length of follow-up time, and total visit count.15 Overall, infection rates seen in a population-based cohort of Medicaid beneficiaries was significantly higher than infection rates previously described.7,8 Incidence rates of serious infections requiring hospitalization, as well as subsequent mortality, were extremely high in this low-income population.7,16 Among children, the risk for serious infection was 1.70 times (95% CI, 1.32-2.20 times) higher among Black patients compared with White patients; among adults, this risk was 1.14 times (95% CI, 1.06-1.21 times) higher.7,16

In Medicaid beneficiaries with SLE, rates of avoidable acute care use for vaccine-preventable illnesses have been found to be significantly higher among Black individuals compared with White individuals.2 In general, vaccinations for these conditions are both safe and efficacious among individuals with rheumatic conditions. While decreased immunogenicity has been suggested with immunosuppressive use, the vaccines still appear to be efficacious.17,18 Despite this, influenza, pneumococcal, and human papillomavirus (HPV) vaccination rates among individuals with systemic rheumatic diseases remain suboptimal.13,19 Black patients with SLE have also been shown to be less likely than White patients to receive vaccine recommendations from their physicians, despite higher risks for serious infections and acute care use for vaccine-preventable illnesses.1,14,15

A multidisciplinary team of experts defined a set of SLE-specific adverse outcomes that could be prevented, or their complications minimized, if timely, effective ambulatory care had been received.20 Using a modified Delphi process, consensus was reached on 25 SLE-specific adverse conditions that were thought to be preventable and of public health importance. Six of the 25 were vaccine-preventable illnesses.8 This strategy was applied to a Medicaid population and it was found that Black individuals compared with White individuals with SLE were significantly more likely to visit the emergency department or be hospitalized for vaccine-preventable infections.13 Research also demonstrated that the uptake of HPV vaccination among children and young adults with systemic inflammatory diseases nationwide was extremely low.10  

Impact of COVID-19 on Rheumatic Disease

Individuals with rheumatic diseases who are Black, Latinx, or Asian vs those who are White have also experienced significantly higher odds of hospitalization for COVID-19.21 Patients with systemic rheumatic diseases may have a higher risk for death from COVID-19 and the use of glucocorticoid medications for rheumatic diseases has also been associated with hospitalization for severe COVID-19.22 The disproportionate burden of current COVID-19 infections in vulnerable populations, including individuals with SLE, accentuates the importance of working to improve avoidable vaccine-preventable illnesses.13

It is imperative that we mobilize our most vulnerable rheumatology patients, and assemble partnerships across health care providers, academic institutions, community members, and policy leaders to thwart racial, ethnic, and socioeconomic disparities vividly demonstrated in the setting of the COVID-19 pandemic. Our fight is not only clinical care-based, but to achieve equity in health that we need moving forward.23

Editor’s Note: A full podcast episode with Dr Ramsey-Goldman and Dr Feldman on the topic of disparities in rheumatology care is available here.  

References

  1. Feldman CH, Hiraki LT, Liu J, et al. Epidemiology and sociodemographics of systemic lupus erythematosus and lupus nephritis among US adults with Medicaid coverage, 2000-2004. Arthritis Rheum. 2013;65:753-763. doi:10.1002/art.37795
  2. Oliver JE, Silman AJ. Why are women predisposed to autoimmune rheumatic diseases? Arthritis Res Ther. 2009;11:252. doi:10.1186/ar2825
  3. Barbhaiya M, Feldman CH, Chen SK, et al. Comparative risks of cardiovascular disease in patients with systemic lupus erythematosus, diabetes mellitus, and in general Medicaid recipients. Arthritis Care Res (Hoboken). 2020;72:1431-9. doi:10.1002/acr.24328
  4. Barbhaiya M, Feldman CH, Guan H, et al. Racial/ethnic variation in stroke rates and risks among patients with systemic lupus erythematosus. Semin Arthritis Rheum. 2019;48(5):840-846. doi:10.1016/j.semarthrit.2018.07.012
  5. Bernatsky S, Ramsey-Goldman R, Joseph L, et al. Lymphoma risk in systemic lupus: effects of disease activity versus treatment. Ann Rheum Dis. 2013;73:138-142. doi:10.1136/annrheumdis-2012-202099
  6. Bernatsky S, Ramsey-Goldman R, Gordon C, et al. Factors associated with abnormal Pap results in systemic lupus erythematosus. Rheumatology (Oxford). 2004;43:1386-1389. doi:10.1093/rheumatology/keh331
  7. Feldman CH, Hiraki LT, Winkelmayer WC, et al. Serious infections among adult Medicaid beneficiaries with systemic lupus erythematosus and lupus nephritis. Arthritis Rheumatol. 2015;67:1577-1585. doi:10.1002/art.39070
  8. Feldman CH, Marty FM, Winkelmayer WC, et al. Comparative rates of serious infections among patients with systemic lupus erythematosus receiving immunosuppressive medications. Arthritis Rheumatol. 2017;69:387-397. doi:10.1002/art.39849
  9. Furer V, Rondaan C, Heijstek M, et al. Incidence and prevalence of vaccine preventable infections in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD): a systemic literature review informing the 2019 update of the EULAR recommendations for vaccination in adult patients with AIIRD. RMD Open. 2019;5:e001041. doi:10.1136/rmdopen-2019-001041
  10. Feldman CH, Hiraki LT, Lii H, Seeger JD, Kim SC. Human papillomavirus vaccine uptake among individuals with systemic inflammatory diseases. PLoS One. 2015;10:e0117620. doi:10.1371/journal.pone.0117620
  11. 11. Feldman CH, Xu C, Williams J, Collins JE, Costenbader KH. Patterns and predictors of recurrent acute care use among Medicaid beneficiaries with systemic lupus erythematosus. Semin Arthritis Rheum. 2020;50(6):1428-1436. doi:10.1016/j.semarthrit.2020.02.012
  12. Nee R, Jindal RM, Little D, et al. Racial differences and income disparities are associated with poor outcomes in kidney transplant recipients with lupus nephritis. Transplantation. 2013;95:1471-1478. doi:10.1097/TP.0b013e318292520e
  13. Feldman CH, Xu C, Costenbader KH. Avoidable acute care use for vaccine-preventable illnesses among Medicaid beneficiaries with lupus: demographic and healthcare utilization differences. Arthritis Care Res (Hoboken). Published online May 4, 2021. doi:10.1002/acr.24628
  14. Lawson EF, Trupin L, Yelin EH, et al. Reasons for failure to receive pneumococcal and influenza vaccinations among immunosuppressed patients with systemic lupus erythematosus. Semin Arthritis Rheum. 2015;44(6):666-671. doi:10.1016/j.semarthrit.2015.01.002
  15. Walunas TL, Jackson KL, Chung AH, et al. Disease outcomes and care fragmentation among patients with systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2017;69(9):1369-1376. doi:10.1002/acr.23161
  16. Hiraki LT, Feldman CH, Marty FM, Winkelmayer WC, Guan H, Costenbader KH. Serious infection rates among children with systemic lupus erythematosus enrolled in Medicaid. Arthritis Care Res (Hoboken). 2017;69:1620-1626. doi:10.1002/acr.23219
  17. Adawi M, Bragazzi NL, McGonagle D, et al. Immunogenicity, safety and tolerability of anti-pneumococcal vaccination in systemic lupus erythematosus patients: An evidence-informed and PRISMA compliant systematic review and meta-analysis. Autoimmun Rev. 2019;18(1):73-92. doi:10.1016/j.autrev.2018.08.002
  18. Liao Z, Tang H, Xu X, Liang Y, Xiong Y, Ni J. Immunogenicity and safety of influenza vaccination in systemic lupus erythematosus patients compared with healthy controls: a meta-analysis. PLoS One. 2016;11:e0147856. doi:10.1371/journal.pone.0147856
  19. Garg S, Tsagaris K, Cozmuta R, Lipson A. Improving the combination pneumococcal vaccination rate in systemic lupus erythematosus patients at an adult rheumatology practice. J Rheumatol. 2018;45(12):1656-1662. doi:10.3899/jrheum.171377
  20. Feldman CH, Speyer C, Ashby R, et al. Development of a set of lupus-specific, ambulatory care-sensitive, potentially preventable adverse conditions: a delphi consensus study. Arthritis Care Res (Hoboken). 2021;73(1):146-157. doi:10.1002/acr.24095
  21. Gianfrancesco MA, Leykina LA, Izadi Z, et al. Race/ethnicity association with COVID-19 outcomes in rheumatic disease: data from the COVID-19 Global Rheumatology Alliance Physician Registry. Arthritis Rheumatol. 2020;73(3):374-380. doi:10.1002/art.41567
  22. Strangfeld A, Schäfer M, Gianfrancesco MA, et al. Factors associated with COVID-19-related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis. Published online January 27, 2021. doi:10.1136/annrheumdis-2020-219498
  23. Feldman CH, Ramsey-Goldman R. Widening disparities among patients with rheumatic diseases in the COVID-19 era: an urgent call to action. Arthritis Rheumatol. 2020;72(9):1409-1411. doi:10.1002/art.41306