EULAR updates vaccination advice for the biologics era

Updated EULAR guidance on vaccination for adults with autoimmune inflammatory rheumatic diseases (AIIRD) includes two new recommendations for household members and for newborns exposed to biologics in utero.

Among the nine recommendations updating 2011 guidance is advice that immunocompetent household members of patients with AIIRD should be encouraged to receive vaccines, with the exception of oral polio vaccines, according to national guidelines.

The oral polio vaccine should be avoided due to the risk of transmission with a small risk of a vaccine-associated paralytic poliomyelitis in immunosuppressed household members.

Live attenuated vaccines should also be avoided during the first six months of life in newborns of mothers treated with biologics during the second half of pregnancy.

“A fatal case of disseminated tuberculosis in a newborn exposed to infliximab and vaccinated with BCG vaccine, underlies the importance to avoid live-attenuated vaccines for at least the first 6 months of life,” the guidelines note.

In a new travel vaccination recommendation, vaccination against yellow fever should be generally avoided in patients with AIIRD.

Since travel to Africa and South America has become popular EULAR advises that withholding immunosuppression to allow safe vaccination may be considered.

Previous recommendations regarding HPV vaccination have been modified since the 2011 EULAR advice.

The new recommendation is for patients with AIIRD and in particular, patients with SLE, to receive vaccination against HPV as per the general population.

It said the main reason for the modification was because the bulk of the evidence for vaccine immunogenicity was in females with SLE.

“This population is at a particular, high risk to contract genital HPV infection, including high-risk serotypes for cervical dysplasia.”

“Population based studies have consistently shown that quadrivalent HPV vaccine was not associated with increased incidence of new-onset autoimmune disease in girls and women

with pre-existing autoimmune disease,” they noted. 

The guidelines also said herpes zoster vaccination may be considered in high-risk patients with AIIRD. The recommendation is unchanged from the 2011 guidelines however more evidence has accumulated to provide further support.

A previous 2011 recommendation that Hepatitis A and hepatitis B vaccines should be administered to AIIRD patients at risk has been expanded in 2019 to include booster or passive immunisation in specific situations such as people travelling to or resident in endemic areas.

Patients with AIIRD should receive tetanus toxoid vaccination as per the general population.

“Passive immunisation should be considered for patients treated with B cell depleting therapy,” the recommendation said.

And both influenza and pneumococcal vaccination should be strongly considered for the majority of patients with AIIRD.

Overarching principles for vaccination in AIIRD are now:

  • Vaccination status and indication for further vaccination should be assessed yearly by the rheumatology team
  • Individualised vaccination programs should be explained to the patient by the rheumatology team, allowing for shared decision making, and joint implementation with primary care
  • Vaccination should preferably be administered during quiescent disease
  • Vaccines should be administered prior to planned immunosuppression esp. B cell depleting therapy
  • Non-live vaccines can be administered to patients with AIIRD while treated with systemic glucocorticoids and DMARDs
  • Live-attenuated vaccines may be considered in caution in patients with AIIRD.

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