Infections are a major concern for people with rheumatic disease, in whom they occur more frequently than in the general population. When they occur, infections in this population tend to be more serious, possibly because of an inherent immune dysfunction associated with the disease or as a complication of the drugs used to control it. Despite the increased risk of infection, however, adults with rheumatic disease are underimmunized for preventable infections, including pneumococcal diseases and influenza, according to Dr. Nora G. Singer, associate professor of pediatric and adult rheumatology at Case Western University in Cleveland. The strength of the protective response mounted by the body following exposure to immunization might not be as robust among individuals whose immune system has been compromised by their disease or their therapy. However, most patients with a rheumatic disease will generate some immune response to immunization against influenza and pneumococcal diseases that will at least lessen the severity of subsequent infection with the relevant microbe, Dr. Singer said at the Congress of Clinical Rheumatology in Destin, Fla., earlier this year. In this Ask the Expert column, Dr. Singer discusses some of the important considerations with respect to immunization in this immune-compromised population. RHEUMATOLOGY NEWS: Given their increased risk of infection, why are adults with rheumatic disease not routinely being vaccinated against influenza and pneumococcus? Dr. Singer: The vaccination rate appears to be between 30% and 40% of those who are candidates for immunization against flu and pneumococcal diseases. Patient and physician factors appear to contribute to undervaccination. Patient issues include worries about side effects, ability to pay, and some patients' perception that they are too healthy to require vaccination. Physician factors include systems problems, such as lack of readily available influenza vaccine at the time it is required, lack of systems to record and track vaccinations within practices, lack of an assigned office support person to routinely offer vaccination to patients, underrecognition of who should be vaccinated, and more individual issues including, but not limited to, concerns that individual patients may not respond to vaccine because of their illness or medication, and that patients may have to pay out of pocket or won't be able to afford the vaccines. RN: Can patients with rheumatic disease who are on immunosuppressant therapies safely be vaccinated against pneumococcal disease and influenza? What are the most important considerations with respect to vaccination in this population? Dr. Singer: Yes, these patients can and should be vaccinated against influenza and pneumococcal disease. Live, attenuated vaccines are considered relatively contraindicated in rheumatic disease patients who are on biologic therapies, so when we talk about vaccines in these patients, we are talking about inactivated vaccines or component vaccines, rather than live, attenuated vaccines. For pneumococcus, a polysaccharide vaccine is available and recommended; for influenza, the inactivated vaccine flu shot, rather than nasal FluMist, is recommended. RN: Do biologic therapies affect vaccine responses? What, if any, treatment modifications should be made? Dr. Singer: Some biologics may reduce the level of immune response to vaccination, but most patients on biologics appear to get some benefit from vaccination, as best we can measure. Patients on anti-tumor necrosis factor-alpha therapy appear to have protective vaccine responses for the most part. In patients treated with costimulatory blockade or B-cell-depleting agents, the timing of vaccination may be important in maximizing vaccine response. Most measurement of vaccine protection depends on measuring antibodies in the blood, which are a surrogate marker for protection. For example, a doubling or quadrupling of antibody in the blood might be what is desired based on previous studies. No one, however, would propose vaccinating a patient with flu vaccine and then purposely exposing that person to influenza in order to directly determine whether the vaccine confers immunity. So instead of challenging patients with the infection against which we are trying to protect them, we measure the antibodies in their blood against the infectious agents. Although some people who have been immunized against influenza might contract it, the hope is that the antibodies they develop as a result of the vaccine will at least result in milder disease. RN: Are there published guidelines for immunization specific to this population? Dr. Singer: The Centers for Disease Control and Prevention has published guidelines that include specific references to immunocompromised hosts (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5540a10.htm?s_cid=mm5540a10_e). In June 2008, the American College of Rheumatology Guidelines Task Force panel recommended that patients with rheumatoid arthritis who are receiving leflunomide, methotrexate, or sulfasalazine can be immunized with inactive viral vaccines in accordance with CDC's relevant recommendations (http://www.lupus.org/webmodules/webarticlesnet/articlefiles/946-shingles.pdf). The ACR Guidelines Task Force recommended avoidance of live viral vaccine preparations with “all biologic agents,” but provided no directives on whether live vaccines are safe with methotrexate or corticosteroid use. Additionally, regarding the zoster vaccine, the ACR disseminated the following advice to its members in 2008: “Until more research becomes available, it is still advisable to avoid the zoster vaccine in patients actively receiving TNF inhibitors, as well as abatacept, rituximab, and anakinra. In some, it may be advisable to delay the initiation of biologic therapy until at least 2 weeks after the zoster vaccine is given.” Dr. Singer reported no relevant conflicts of interest. http://www.rheumatologynews.com/article/S1541-9800(09)70157-7/fulltext