Vaccinations in Rheumatic Diseases

A vaccine produces immunity against a particular disease by stimulating immune system. It prevents or reduces the severity of future infections by a particular organism. Vaccines are of various types. They usually contain the microorganism (bacterium or virus – killed or attenuated) or its toxic products. Our body recognizes vaccine as a foreign agent and kills or destroys it. Memory cells come into play during infections with the same microorganism which is then destroyed and disease averted.

Patients with autoimmune diseases are at increased risk of developing infections. Risk of infection in patients with rheumatoid arthritis is almost double as compared to normal population. Patients with systemic lupus erythematosus, too, have significantly higher risk of infection. Infection is an important cause of mortality in these cases. Immunomodulatory or immunosuppressive treatment of these diseases makes patients more susceptible to infections although it is generally accepted that low doses of drugs used in rheumatology practice are not severely immunosuppressive. Glucocorticoids (steroids), methotrexate, cyclophosphamide, leflunomide, azathioprine, anti-TNF agents (etanercept, infliximab, adalumumab, golimumab) and other biological agents (anakinra, rituximab, abatacept, tocilizumab) are the main immunomodulators used in rheumatology practice.

The quality of preventive response appears to be inferior in patients with autoimmune diseases. This may be due to the disease itself or to the immunomodulator therapy. Efficacy of vaccinations appears to be lower in patients on anti-TNF and agents but normal in patients on methotrexate and azathioprine. This may mean more frequent vaccination with booster doses. A small risk of development of an autoimmune disease following vaccination is postulated as infections can trigger autoimmune response. A transient increase in joint pains has been observed after many vaccines although the risk of development of rheumatoid arthritis does not increase. There is no evidence to suggest that vaccines increase disease activity or lead to a flare in these diseases.

Live vaccines should not be used in autoimmune inflammatory diseases. These include measles, mumps, rubella, yellow fever, typhoid and BCG (for tuberculosis).Attenuated vaccines are safe but require booster doses. In some cases it may be better to use immunoglobulins or anti-viral/anti-bacterial drugs for prevention or treatment of these diseases.

Diphtheria, TetanusEvery 10 years
Whooping coughOne booster in adults
Polio, choleraNo live vaccine. Use killed vaccine
Measles, Mumps, RubellaContraindicated
Tuberculosis (BCG)Contraindicated
Pneumococcal pneumoniaEvery 5 years
InfluenzaEvery year
Swine flu (Nasal – attenuated)Every year. Killed attenuated safer.
Herpes zoster, Hepatitis BSafe
Hepatitis ASafe
Japanese encephalitisSafe
TyphoidNo live vaccine. Use Vi capsular polysaccharide vaccine
RabiesUse inactivated vaccine after dog bite