Prevention of infection is important in the management of autoimmune inflammatory rheumatic diseases (AIIRD), but uptake of vaccinations is suboptimal in patients with AIIRD worldwide. In light of new data on the prevalence and incidence of vaccine-preventable infections in adults with AIIRD, as well as on the efficacy, immunogenicity and safety of available vaccines, EULAR has issued updated recommendations for vaccinations in these patients.

The 2019 update comprises six overarching principles and nine recommendations, formulated by an international group of experts and based on a comprehensive systematic literature review. “Since the first version of EULAR recommendations on vaccination of adult patients with AIIRD was published in 2011, there has been a large expansion in the amount of available evidence on this topic, necessitating an update,” says lead author Victoria Furer.

Notably, the EULAR task force used clear outcome measures of vaccination when evaluating this evidence. “In the AIIRD population, the data on the clinical efficacy of vaccination is limited,” explains Furer. “Thus, ‘immunogenicity’ of vaccination was used as a surrogate marker of efficacy, when appropriate. The strength of recommendations was based on the level of the data. For example, in case of lack of a direct correlation between the immunogenicity outcomes and the level of protection, the strength of recommendation was downgraded.”

The overarching principles stress the need for regular assessment, patient education and shared decision-making. “We hope that this recommendation will improve the implementation of the vaccination programme,” notes Furer. The principles also state that vaccines should be administered during quiescent disease and before planned immunosuppressive therapy, and that non-live vaccines can be given to patients being treated with glucocorticoids and/or DMARDs. Live-attenuated vaccines should be avoided during immunosuppression but, in a modification of the 2011 recommendations, MMR and herpes zoster vaccines can be considered with caution.

The core set of recommendations concerning influenza, pneumococcal, tetanus toxoid, hepatitis A, hepatitis B and HPV vaccinations remained essentially unchanged from the 2011 recommendations, with some minor modifications. Several of the 2011 recommendations were omitted from the 2019 update; two, concerning BCG vaccination and vaccination of hyposplenic or asplenic patients with AIIRD, had become irrelevant to clinical practice and one, concerning travelling patients, was deemed non-specific. New recommendations were added to encourage the vaccination of immunocompetent members of the households of patients with AIIRD, to avoid vaccination with live-attenuated vaccines for the first 6 months of life in newborns exposed to biologic drugs during the late stages of pregnancy and to avoid vaccination against yellow fever in patients with AIIRD during immunosuppression.

“The implementation of the present recommendations will help in prevention of infections in the susceptible population of patients with AIIRD,” Furer contends. “In particular, dissemination of the main principles of these recommendations among the health professionals, including primary care teams, treating patients with AIIRD is of great importance. Thus, a number of educational projects for the medical community to increase the awareness of vaccination and compliance with the recommendations are underway.”