Vaccination in rheumatology

Vaccination guidance in rheumatology patients

Patients who have autoimmune inflammatory rheumatic diseases (AIIRD) are more prone to infections and the risk is further increased when patients are treated with immunosuppressive therapies¹. Vaccinating these patients confers immunity against infections and possible hospital admissions.

Individuals managed on immunosuppression should be given inactivated vaccines in accordance with national recommendations.

Please note it is not necessary to submit a referral form for routine vaccination for patients in your care who become eligible based on their age or clinical coding. The patient will be called forward in line with the clinical order of priority.

The specialist service is responsible for referring patients for vaccinations out with the routine vaccination schedules.

Information for how to refer to the patient’s local health and social care partnership (HSCP) can be found HSCP Vaccination Service. 

1. Pneumococcal and influenza vaccinations

Patients with AIIRD are at a higher risk of developing pulmonary infections and contracting influenza compared to the general population.

It is recommended that all patients with AIIRD receive the pneumococcal (PPV23) vaccination and annual influenza vaccination (inactivated form).²

Evidence on the frequency of revaccination for the pneumococcal vaccination is mixed. Antibody levels are likely to decline rapidly in individuals with asplenia, splenic dysfunction or chronic renal disease and, therefore, re-immunisation with PPV23 is recommended every five years in these groups³.

• Patients on specific drug therapies

Ideally, the above vaccinations should be administered 2 weeks prior to commencing immunosuppressive therapies (4 weeks if using rituximab)⁴ to ensure adequate antibody production.  This may not always be possible; therefore the pneumococcal and influenza vaccinations can be administered at any time. However, in such circumstances the response rate to inactivated vaccines tends to be reduced in immunocompromised versus immunocompetent patients.⁴

2. Live vaccines

Live vaccines currently available in the UK are:

• Live influenza vaccine (Fluenz Tetra)
• Measles, Mumps and Rubella vaccine (Priorix, MMRVaxPro)
• Rotavirus vaccine (Rotarix)
• Shingles vaccine (Zostavax)
• BCG vaccine
• Oral typhoid vaccine (Ty21a)
• Varicella vaccine (Varilrix, Varilvax)
• Yellow Fever vaccine

Live vaccines should not be administered to individuals on immunosuppressive therapy including:

 ●● Individuals who are receiving, or have received in the past 6 months, immunosuppressive chemotherapy or radiotherapy for malignant disease or non-malignant disorders

 ●● Individuals who are receiving, or have received in the past 6 months, immunosuppressive therapy for a solid organ transplant (with exceptions, depending upon the type of transplant and the immune status of the patient)

●● Individuals who are receiving or have received in the past 12 months immunosuppressive biological therapy (e.g. anti-TNF therapy such as alemtuzumab, ofatumumab and rituximab) unless otherwise directed by a specialist

 ●● Individuals who are receiving or have received in the past 3 months immunosuppressive therapy including:

• Adults and children on high-dose corticosteroids (>40mg prednisolone per day or 2mg/ kg/day in children under 20kg) for more than 1 week
• Adults and children on lower dose corticosteroids (>20mg prednisolone per day or 1mg/kg/day in children under 20kg) for more than 14 days
• Adults on non-biological oral immune modulating drugs e.g. methotrexate >25mg per week, azathioprine >3.0mg/kg/day or 6-mercaptopurine >1.5mg/kg/day

• Patients on specific drug therapies

Patients who have received live viral vaccines due to commence immunosuppressive therapy should  wait a period of 4 weeks. However, since most of the vaccines viruses are attenuated, delays in treatment should not occur if the patient’s condition will worsen as a result.

3. COVID-19 vaccination

The Joint Committee on vaccination and immunisation (JCVI) issued a report in July 2023 ⁶, advising that for Autumn 2023 the following groups should be offered COVID-19 vaccination:

• Residents in care homes for older adults
• All adults aged 65 years and over
• Frontline health and social care workers
• Persons aged 6 months to 64 years in a clinical risk group, as set out in table 3 and 4 of the COVID-19 chapter on the Green Book. 
• Persons aged 12 to 64 years who are household contacts, as defined in the Green Book, of people with immunosuppression
• Persons aged 16 to 64 years who are carers, as defined in the Green Book, and staff working in care homes for older adults

References

• Furer V, Rondaan C, Heijstek M.W et al. (2019). Update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases Annals of the Rheumatic Diseases Published Online First: 14 August 2019. doi: 10.1136/annrheumdis-2019-215882.
• Holroyd C.R, Seth R, Bukhari M et al. (2019). The British Society for Rheumatology. Biologic DMARD safety guidelines in inflammatory arthritis. Rheumatology. 58:2, e3-42.
• Public Health England. The Green Book. Chapter 7: Immunisation of individuals with underlying medical conditions. Updated November 2020. Available from https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book (accessed May 2023).
• British Society of Rheumatology. (2011). Guidelines on the use of rituximab in rheumatoid arthritis. Available from https://academic.oup.com/rheumatology/article/50/12/2311/1789192 (accessed May 2023).
• Public Health England. The Green Book. Chapter 6: Contraindications and special considerations. Updated August 2017. Available from https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book (accessed May 2023).
• JCVI statement on the COVID-19 vaccination programme for autumn 2023 – update 7 July 2023. GOV.UK. [cited 2023 Nov 6]. Available from: https://www.gov.uk/government/publications/covid-19-autumn-2023-vaccination-programme-jcvi-update-7-july-2023/jcvi-statement-on-the-covid-19-vaccination-programme-for-autumn-2023-update-7-july-2023 (accessed November 2023)

M.A & S.R/H.B. 25-01-24