Vaccinations
For her talk, Jenna Thomason, MD, MPH, acting instructor in the Division of Rheumatology at the University of Washington, used a work in progress Venn diagram to discuss the preventative medicine responsibilities of vasculitis patients, their medical team and both. To the avid interest of many attendees, she spent most of her time on the complicated topic of vaccinations.
Live virus vaccinations are contraindicated in patients on immunosuppressive medications, she reminded the group. For others, “timing really, really matters.” Ideally, patients should be vaccinated before they start steroid or biologic therapy, since multiple medications can impair the immunogenic response and, thus, the vaccine efficacy.
Immunosuppressed patients are a particularly high priority for the yearly influenza vaccination that contains inactivated versions of the virus. To overcome many patients’ strong opinions about why they shouldn’t take it, Dr. Thomason said she emphasizes its importance in reducing their risk of being hospitalized or worse.
During the 2017–2018 flu season, the CDC estimated that more than 900,000 Americans were hospitalized, and roughly 80,000 died. A 2018 study in New Zealand found that among hospitalized patients who tested positive for influenza, vaccination was associated with a 59% reduction in their odds of being admitted to the ICU.2
To help prevent pneumococcal infections, patients can now take two vaccines: Pneumovax 23 and Prevnar 13. Doctors often call them pneumonia vaccines, Dr. Thomason said, but she emphasized that they protect against invasive pneumococcal infections, such as meningitis and bacteremia, as well. Because each vaccine causes the other to be less immunogenic, she explained, doctors must wait after the first before delivering the second: at least eight weeks if they start with Prevnar 13 and at least 12 months if they start with Pneumovax 23.
Vaccination against shingles is another high priority for vasculitis patients, particularly because patients on immunosuppressive therapies are at higher risk for the painful and potentially serious viral infection. The initial Zostavax option hasn’t been available to all patients since it’s a live virus vaccine; it also has an overall efficacy of about 50% (64% among patients 60 to 69 years old, but protection drops significantly with advancing age).
Fortunately, Dr. Thomason said, a new two-dose vaccine, Shingrix, is far more effective and has been approved for all patients who are 50 or older. According to the CDC, “In adults 50 to 69 years old who got two doses, Shingrix was 97% effective in preventing shingles; among adults 70 years and older, Shingrix was 91% effective.” Dr. Thomason said the Shingrix vaccine also protects against postherpetic neuralgia, which can develop after shingles and lead to ongoing, severe pain.
