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EULAR: MMR, Herpes Zoster Vaccines Permitted With Immunosuppressive Therapies

Furer V, et al. Ann Rheum Dis. 2019;doi:10.1136/annrheumdis-2019-215882.
Healio Rheumatology, October 2019

EULAR recommendations now state that vaccines for measles, mumps and rubella, as well as herpes zoster, may be considered with caution in adult patients with autoimmune inflammatory rheumatic diseases at risk, according to a 2019 update published in the Annals of the Rheumatic Diseases.

“Since the first version of EULAR recommendations on vaccination of adult patients with autoimmune inflammatory rheumatic diseases (AIIRD) was published in 2011, there has been a large expansion in the amount of available evidence on this topic, necessitating an update,” Victoria Furer, MD, of the Tel Aviv Sourasky Medical Center, in Israel, told Healio Rheumatology. “The updated recommendations incorporate the new evidence on efficacy, immunogenicity and safety of vaccination in patients with AIIRD, providing a practical guidance for healthcare professionals treating patients with AIIRD.”

Victoria Furer

To update the 2011 EULAR recommendations for vaccinations among adult patients with autoimmune inflammatory rheumatic diseases, Furer and colleagues formed a task force of 21 experts — including rheumatologists, immunologists, two patients, an infectious disease specialist and one health professional in rheumatology — from eight countries. Members conducted four systematic literature reviews regarding the incidence and prevalence of vaccine-preventable diseases in patients with autoimmune inflammatory rheumatic diseases, as well as efficacy, immunogenicity and safety, and the impact of anti-rheumatic drugs on vaccine response.

The task force used the results of the literature reviews and expert opinion to draft changes to the recommendations. Each recommendation was discussed, modified when necessary and approved in two rounds of voting by all members of the task force.

The task force modified the original 11 recommendations published in 2011, releasing a series of six overarching principles and nine recommendations in their 2019 update. Three of the overarching principles were based on three of the previous 2011 recommendations. These are:

  • Vaccinations in patients with autoimmune inflammatory rheumatic diseases should be given when the disease is inactive.
  • Vaccines should preferably be given prior to immunosuppression.
  • Non-live vaccines can be given to patients with autoimmune inflammatory rheumatic diseases during treatment with glucocorticoids and DMARDs.

There are also three new overarching principles. These are:

  • Vaccination status, and the need for further vaccination, in patients with autoimmune inflammatory rheumatic diseases should be re-assessed annually by the rheumatology team.
  • Individual vaccination plans should be explained to the patient, allowing for shared decision making and implementation between the rheumatology team, the primary care physician and the patient.
  • Live-attenuated vaccines may now be considered with caution in patients with autoimmune inflammatory rheumatic diseases. 

That final overarching principle represents a departure from the 2011 recommendations, which stated that live-attenuated vaccines should be avoided when possible in patients with autoimmune inflammatory rheumatic diseases undergoing immunosuppression. However, the 2019 update states that exceptions can be made for the herpes zoster (HZ) and measles, mumps and rubella (MMR) vaccines.

“In summary, live-attenuated vaccines should be avoided during immunosuppression, with a possible exception of a cautious use of MMR booster and HZ vaccine under special circumstances, as discussed above,” Furer and colleagues wrote.

Regarding the recommendations themselves, the updated list includes three completely new items that were not part of the initial 2011 publication. These new recommendations are:

  • The use of yellow fever vaccines should be “generally avoided” in patients with autoimmune inflammatory rheumatic diseases;
  • Immunocompetent household members of patients with autoimmune inflammatory rheumatic diseases should receive vaccines according to national guidelines, except for oral polio vaccines; and
  • Live-attenuated vaccines should be avoided during the first 6 months of life if the mother had been treated with biologics during the second half of pregnancy.

The remaining six updated items come from the original 2011 recommendations, some with modifications and some unchanged. These new recommendations state that vaccinations against influenza and pneumonia should be “strongly considered” for most patients with autoimmune inflammatory rheumatic diseases. In addition, patients with autoimmune inflammatory rheumatic diseases should receive vaccination against toxoid tetanus according to guidelines for the general population, although passive immunization should be considered for patients treated with B-cell depleting therapy.

The recommendations also state that hepatitis A and B vaccines should be given to at-risk patients with autoimmune inflammatory rheumatic diseases, with booster or passive immunization indicated for specific situation. Lastly, herpes zoster vaccination can be considered for high-risk patients with autoimmune inflammatory rheumatic diseases.

“New items addressing the vaccination of an AIIRD patient’s environment, including household members and newborns of mothers treated with biologics during pregnancy, were added,” Furer said. “Immunocompetent individuals, who live in a household with immunosuppressed patients, should be vaccinated according to national guidelines. Oral polio vaccine should be avoided due to a risk of transmission to household members. Highly immunocompromised patients should avoid handling diapers of infants vaccinated against rotavirus for at least 4 weeks following the administration of the vaccine.”

“Live-attenuated vaccines should be avoided during the first 6 months of life in newborns of mothers exposed to anti-TNF biologics during the second half of pregnancy,” she added. “The implementation of the present recommendations will help in prevention of infections in the susceptible population of patients with AIIRD.” – by Jason Laday