BY NEHAL HAMDY

EULAR recommendations for vaccination in adult patients with

autoimmune inflammatory rheumatic diseases

• The vaccination status should be assessed in the initial work-up of patients with AIIRD (no grade of evidence possible; strength of recommendation D; Delphi vote 9.50)

• Vaccination in patients with AIIRD should ideally be administered during stable disease (no grade of evidence possible; strength of recommendation D; Delphi vote 8.88)

Live attenuated vaccines should be avoided whenever possible in immunosuppressed patients with AIIRD (grade of evidence IV; strength of recommendation D; Delphi vote 9.25)

Live attenuated vaccine

Viral: • measles vaccine• mumps vaccine•  rubella vaccine• Live attenuated influenza vaccine( 2009 H1N1 flu) • chicken pox vaccine• Oral polio vaccine •  rotavirus vaccine•  yellow fever vaccine•  Rabies vaccines • herpes zoster vaccine Bacterial:•  BCG vaccine•  typhoid vaccine

Vaccination in patients with AIIRD can be administered

during the use of disease-modifying anti rheumatic drugs and

tumor necrosis factor α blocking agents but should ideally

be administered before starting B cell depleting

biological therapy (grade of evidence IIa; strength of

recommendation B; Delphi vote 9.13)

The use of live vaccines is contra-indicated unless immunosuppressive are stopped at least 3 months beforehand.

Salazopyrine shouldn’t be given in combination with varcillea vaccine for fear of Reye syndrome.

DMARD & ANTI TNF

Azathioprine decreased the effacy influenza vaccination in patients with SLE .

The combination of TNFα blocking agents and MTX reduced the response to pneumococcal vaccination in patients with RA.

Rituximab

Humoral responses following influenza &pneumococcal vaccination 1–3 months after treatment are severely decreased.

when patients are on rituximab already, vaccines are given at least 6 months after the start but 4weeks before the next course.

Patients on steroids

no contraindication to give killed vaccine.

Live vaccines must not be given to patients taking moderate or high doses of steroids for longer than 2 weeks.

There are no contra-indications to using live vaccines if:• Steroid is for less than 2 weeks.• Treatment is alternate day with short acting steroid.• By topical application.• By intra articular or soft tissue injection.• Long term low dose steroids (10mg per day or less).Moderate or high dose steroid must be stopped 3 months

before live vaccines can be administered.

Inactivated influenza vaccination should be strongly considered for patients with AIIRD (grade of evidence Ib–III; strength of recommendation B–C; Delphi vote 9.00)

Influenza vaccination has been shown to reduce mortality from pneumonia in patients with RA, SLE, and SSc (Stojanovich L.,2008)

Trade name of seasonal influenza vaccineVaxigripFluarixInfluvac

23-valent polysaccharide pneumococcal vaccination (23-PPV)should be strongly considered for patients with AIIRD (grade of evidence Ib–III; strength of recommendation B–C; Delphi vote 8.19)

Trade name of pneumococcal vaccine• Pneumovax 23• Prevenar 13• Pneuimmune 23

Patients with AIIRD should receive tetanus toxoid vaccination in accordance to recommendations for the general population.

In case of major and/or contaminated wounds in patients who received rituximab within the last 24 weeks, passive immunization with tetanus immunoglobulins should be administered (grade of evidence II;strength of recommendation B–D; Delphi vote 9.19).

In patients with RA and SLE, efficacy for tetanus toxoid vaccination has been demonstrated to be comparable with healthy controls.

Herpes zoster vaccination may be considered in patients with AIIRD (grade of evidence III–IV; strength of recommendation C–D;Delphi vote 8.00)

Based on increased risk of herpes zoster in patients with rheumatological disorder.

Herpes zoster vaccine has been shown to reduce herpes zoste rand post-herpetic neuralgia in patients over 60 years.

However no studies have been performed in patients with AIIRD.

Human papilloma virus vaccination should be considered in selected patients with AIIRD (grade of evidence III; strength of recommendation C–D; Delphi vote 8.44)

SLE patients have increased risk to develop cancer cervix 2ndry to HPV infection compared to healthy population.

In hyposplenic/asplenic patients with AIIRD infl uenza,pneumococcal, Haemophilus influenzae b and meningococcal C vaccinations are recommended (grade of evidence IV; strength of recommendation D; Delphi vote 9.50)

asplenic patients are at risk of contracting a so called ‘overwhelming post-splenectomy infection (OPSI)’. OPSIis caused by encapsulated bacteria (eg, Streptococcus pneumoniae H influenzae b, Neisseria meningitidis ) and the mortality of OPSI isup to 70%.

Hepatitis A and/or B vaccination is only recommended inpatients with AIIRD at risk (grade of evidence II–III; strength of recommendation B–D; Delphi vote 9.13)

Vaccination forhepatitis A and/or B is only recommended when the risk ofcontracting these infections is increased

(travel to or residence in endemic countries for hepatitis A and/or B);

increased riskof exposure to hepatitis A and/or B (eg,medical profession, infected family member)

Patients with AIIRD who plan to travel are recommended to receive their vaccinations except for live attenuated vaccines which should be avoided whenever possible in immunosuppressed patients with AIIRD (no grade of evidence; strength of recommendation D; Delphi vote 9.25)

BCG vaccination is not recommended in patients with AIIRD(grade of evidence III; strength of recommendation C–D;Delphi vote 9.38

BCG vaccine considered to be given in juvenile arthritis 4weeks before immunosuppressives.