Introduction
Vaccinations are a way of preventing infections before they happen. Vaccines help the immune system to recognise viruses and bacteria that cause disease.
Recommendations give advice to doctors and patients about the best way to treat and manage diseases. EULAR published in 2011 the current recommendations on vaccination for people with autoimmune inflammatory rheumatic diseases such as rheumatoid arthritis, lupus or sclerosis.
The recommendations were written by doctors. They looked at the evidence on the use of vaccines in people with autoimmune conditions. They also discussed their expert opinion to achieve a level of agreement.
What do we already know?
People with autoimmune inflammatory rheumatic diseases have weakened immune systems because of the drugs they take and because of the disease itself. Hence they are more likely to get infections than other people.
What do the recommendations say?
Overall, there are 13 recommendations. Each recommendation is based on available scientific evidence or expert opinion. The more stars a recommendation has the stronger (more) the evidence is and the more important it is that you and your doctor follow it.
One star (*) means it is a weak recommendation with limited evidence.
Two stars (**) means it is a weak recommendation with some evidence.
Three stars (***) means it is a strong recommendation with some evidence.
Four stars (****) means it is a strong recommendation with a lot of evidence.
- People with autoimmune inflammatory rheumatic diseases should have their vaccination status checked when they are first diagnosed.*
It is important that your doctor knows what vaccines you have had in the past. You might need to have some vaccines before you can start your treatment. This includes ‘flu, hepatitis, rubella and tetanus.
- Vaccines should be given while your disease is stable.*
There is less chance of your disease getting worse (flaring) if you receive vaccinations while your medical condition is stable
- Live vaccines should be avoided.*
Live vaccines contain small amounts or parts of the real virus or bacteria. Live vaccines should not be used where the immune system might be weakened. They may cause infections.
- Vaccines can be given at the same time as some treatments for your rheumatic disease.***
You can carry on taking DMARDs and TNF-inhibitors (e.g. Enbrel [also called etanercept], Humira [adalimumab], Remicade [infliximab], Cimzia [certolizumab pegol] or Simponi [golimumab]) before and after receiving a non-live vaccine. These medicines will not affect how the vaccine works. If you are taking B cell depleting medicines (e.g. Mabthera [also called rituximab]) your vaccines will need to be carefully timed.
- You should receive a ‘flu vaccination.**/***
People with a rheumatic disease ¬– especially older people – who receive a non-live ‘flu vaccine are less likely to die from ‘flu, pneumonia or other lung infections.
- You should receive a pneumococcal vaccination.**/***
People with a rheumatic disease – especially older people – who receive the polysaccharide pneumococcal vaccine are less likely to die from lung infections.
- You should receive a tetanus vaccination.*/**/***
You can have the tetanus vaccine as often as healthy people. If you get a wound or cut and need a tetanus vaccine, make sure your doctor knows which medicines you are taking for your rheumatic disease. You may need a different type of tetanus vaccine if you are taking B cell depleting medicines (e.g. Mabthera [also called rituximab]).
- You might need a vaccine against herpes zoster.*/**
People with rheumatic diseases are more likely to get herpes zoster (shingles). You can be vaccinated against herpes zoster if your immune system is strong enough.
- Women under the age of 25 with lupus should be vaccinated against HPV.*/**
Human papilloma virus (HPV) is more common in people with lupus. This virus has been linked with cancer of the cervix (the neck of the womb). Young women should have the HPV vaccine.
- People with problems in their spleen should have specific vaccinations.*
If your spleen doesn’t work properly (hyposplenic or asplenic) you should receive ‘flu, pneumococcal, Haemophilus influenzae B and meningococcal C vaccinations. This is particularly important if you live in an area where meningococcus is common.
- You might need a vaccine against hepatitis.*/**/***
You might need a vaccine against hepatitis A or hepatitis B if you live in or travel to an area where hepatitis is common or have otherwise increased risk of exposure (e.g. profession).
- You can take all normal non-live travel vaccines.*
If you are going on holiday you can take all the normal recommended vaccines for the area you are travelling to, unless they are live vaccines. Live vaccines contain small amounts or parts of the real virus or bacteria. These vaccines should not be used if the immune system might be weakened as they may cause infections.
- BCG vaccination is not recommended.*/**
BCG is a vaccine used to protect against tuberculosis, but it may cause disease in people with weakened immune systems.
Summary
Overall, the recommendations say that vaccines are important in people with autoimmune inflammatory rheumatic diseases. The recommendations advise patients with an autoimmune inflammatory rheumatic disease of the steps they can take to protect themselves from infections. When you go for a vaccine you should always tell the doctor or nurse about your rheumatic disease and any medicines you are taking.
If you have any questions or concerns about vaccines, you should speak to your doctor.
This is the lay version of the EULAR recommendations for the vaccination of adults with autoimmune inflammatory rheumatic diseases. The original publication can be downloaded from the EULAR website: www.eular.org.
van Assen A, et al. EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2011;70:414–22. doi:10.1136/ard.2010.137216
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