Vaccinations in Rheumatology
Key message: Please get vaccinated. It’s a complex area, so will require discussion between you, your GP and rheumatologist. An infectious diseases specialist may need to be involved.
Why should I get vaccinated?
- People with rheumatologic conditions such as rheumatoid arthritis, psoriatic arthritis and lupus often suffer infections which can be prevented by vaccination.
- These infections may be more severe in people with these conditions.
- If vaccinated, you will be less likely to get the infection you’ve been vaccinated against. Even if you are infected, it is more likely to be a milder illness.
- Many vaccines (e.g., the influenza vaccine) are free for rheumatology patients taking medication such as prednisolone or methotrexate (MTX), and for people with chronic conditions.
Are there risks with vaccinations?
- There is a small risk (less than 5 in 100) of a reaction (redness, itch, pain) at the injection site.
- The risk of more serious side effects is very low (less than 1 in 10,000).
- It is far more likely that the benefits (good things) will outweigh the risks (bad things).
What vaccines should I consider?
- It is important your vaccines are kept up to date, including influenza and pneumonia – more detail below.
- It’s a tricky area, so you should talk to your general practitioner (GP) and/or rheumatologist about which vaccines are appropriate for you
Are there vaccines to avoid?
“Live” vaccines should be avoided if you are taking medication such as prednisolone at a dose of 20 mg or more a day or a biologic (see Zostavax). This is because live vaccines contain a small dose of virus which can cause infection if the immune system is reduced. For this reason, most vaccines are not live.
Common live vaccines in Australia:
Herpes zoster (Zostavax/shingles) and varicella (chicken pox) vaccine
For children: Rotavirus
- Yellow Fever
- Oral typhoid vaccine
- BCG (Bacille-Calmette–Guérin) vaccine
- Japanese encephalitis vaccine
Herpes zoster (shingles)
Shingles is a disease caused by reactivation (“waking up”) of the chickenpox virus. It causes painful fluid-filled blisters along the course of a nerve, e.g. on the trunk or in the eye. It is relatively common (1 in every 100 people) – especially in older people and in people with certain types of arthritis taking medication which turns “off” the immune system a bit.
Sometimes the pain is still there after the blisters go away. This is called “post-herpetic neuralgia” and is due to the virus damaging the nerve. It can last a long time.
Herpes zoster vaccine (Zostavax)
Zostavax contains a live but weakened virus and is used in those who have had chickenpox before (most people in Australia) to prevent shingles. The Australian National Immunisation Programme provides free Zostavax for people who are 70 years or older. Otherwise, Zostavax has to be paid for.
Can I have Herpes Zoster vaccine (Zostavax) while taking prednisolone or methotrexate?
Yes. Low-dose corticosteroid/cortisone (equivalent to prednisolone ≤ 20 mg per day) and medication which turns “off” the immune system a bit such as Salazopyrin/sulfasalazine or MTX (<25 mg per week) do not need to be stopped before getting Herpes Zoster vaccine.
What about if I’m taking a biologic or targeted synthetic medication?
Biologics such as adalimumab, (Humira), etanercept (Enbrel), tocilizumab (Actemra) or targeted synthetic medication such as tofacitinib (Xeljanz) and baricitinib (Olumiant) are drugs which have markedly improved the lives of rheumatology patients. However, they turn “down” the immune system more than prednisolone or MTX.
It’s difficult to give firm advice as there isn’t enough research, but it’s safer to stop a biologic or targeted synthetic medication before getting Herpes Zoster vaccine and to recommence after Herpes Zoster vaccine or to have Herpes Zoster vaccine before commencing these medications. As there are different types of biologics, please discuss with your rheumatologist regarding the timing of stopping and restarting.
NB: See your GP or rheumatologist as soon as possible should you get a viral illness or fluid-filled skin blisters after receiving Zostavax as this may mean a bout of herpes infection from the vaccine. (This is unlikely).
How about the influenza vaccine?
If you are taking medication such as prednisolone or MTX, which turn “off” the immune system a bit, you are more likely to get severe influenza (the “flu”). Please get the influenza vaccination every year.
Depending on your age, there are different types of influenza vaccine, but your GP will know which one to use. Influenza vaccine should not worsen your rheumatologic condition. As influenza vaccine contains killed virus, it cannot give you the “flu”. You therefore do not need to stop medication that turns “off” your immune system. Fluvax only contains 3-4 strains of the virus so it won’t protect you against every virus out there.
You should get influenza vaccine before the start of the flu season as protection is greatest in the first 4 months after vaccination. Discuss the timing with your GP or rheumatologist.
If a new influenza virus is detected, for example during an influenza pandemic, people who have lowered immunity (such as rheumatology patients) should receive 2 does of inactivated influenza vaccine at least 4 weeks apart, regardless of previous influenza vaccine.
How about the “pneumonia” or pneumococcal vaccine?
Again, if you are taking medication such as prednisolone, MTX or a biologic, which turn “off” the immune system a bit, you are more likely to get severe lung infection (pneumonia) from a bacteria called “Strep pneumonia”. This can be prevented by the vaccine – which does not contain a live bacteria. You therefore cannot get pneumonia from it, nor do you need to stop rheumatology medication beforehand. Two different pneumococcal vaccines are available.
If you have never received the pneumococcal vaccine before, you should get the Prevenar-13 (13vPCV) vaccine first, and then, 2-12 months later, the Pneumovax-23 (23vPPV).
If you have received the pneumococcal vaccine (Pneumovax-23 or 23vPPV) before, we recommend the Prevenar-13 (13vPCV) vaccine 1 year after the Pneumovax-23 (23vPPV).
Talk to your GP about a booster dose of Pneumovax-23 (23vPPV) at least 5 years later.
- There are lots of travel vaccines and which ones you need will depend on where you are going.
- Talk to your GP at least 6 months before travelling.
- If you are taking medication such as prednisone, MTX or a biologic which turn “off” your immune system a bit, you may need to avoid “live” travel vaccines such as Yellow Fever.
- Some countries require the Yellow Fever vaccine to enter or leave. The strong recommendation is to avoid travelling to areas where Yellow Fever is common if on medication which lowers immunity. However, if you need to go, please discuss the risks of vaccination versus risk of the disease with your doctor.
What about the rotavirus vaccine for my baby? Biologic medicine, other than certolizumab (Cimzia), taken during pregnancy and breast-feeding will cross the placenta and enter the baby’s blood. They will also enter breast milk. As a result, your baby’s immune system may also be turned down a bit, so live vaccines for your baby should be avoided until they are weaned.
Rotavirus can cause severe diarrhoea in babies. The rotavirus vaccine is the only live vaccine routinely given to babies less than 12 months old. It is probably best avoided in babies less than 6 months old born to mothers taking biologics, except for certolizumab (Cimzia) which does not enter breast milk. The other live vaccines [(measles-mumps-rubella and varicella (chickenpox)] are given at 12 months of age or more. The likelihood of rotavirus infection is less in infants younger than 6-months old, so if the vaccine is missed, a “catch-up” dose is probably not needed. Every baby in Australia gets rotavirus vaccine, so there’s only a low chance your baby will be infected with rotavirus. If your baby does not have the rotavirus vaccine, you will need to discuss the implications (e.g. for child-care) with your GP and/or your immunisation provider.
Useful references for your GP
Wong PKK, Young L, Johnson DF. Vaccination of patients with autoimmune inflammatory rheumatic disease. Medicine Today 2019; 20(7): 50-53.
Wong PKK and Johnson DF. Live vaccinations and immunocompromised patients. How can GPs ensure this cohort is safely protected against disease? Medical Observer, 14th August 2019.
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