“The H1N1 guidelines from the Centers for Disease Control and Prevention [CDC] strongly suggest vaccinations for the immunocompromised or suppressed individual,” says Daniel E. Furst, MD, Carl M. Pearson professor of rheumatology at the University of California, Los Angeles. “For patients with rheumatological disease, there is a higher risk for morbidity and mortality because of the underlying chronic disease and, more importantly, the immunosuppression.” There apparently has been little research into both the safety and efficacy of the H1N1 vaccine in immunocompromised patients or those with rheumatic disease. However, research into the seasonal vaccine shows it is effective in this cohort.
“There are fairly good data suggesting that patients on immunosuppressant medications do receive benefit from the seasonal flu vaccine,” says Dr. Sullivan. “They do make antibodies and that does give protection. There will be exceptions and not all patients will respond equally well to the vaccine.”
Treatment Guidance May Change
Experts suggest that rheumatologists keep up with possible changes in guidelines for administering the H1N1 vaccine. Because it is new vaccine for a new flu strain, it is expected that what is known about the disease and how to treat it will evolve.
We are waiting for further guidance from the CDC regarding the optimal number of doses to be given in immunocompromised patients.
—Camille N. Kotton, MD
“We are waiting for further guidance from the CDC regarding the optimal number of doses to be given in immunocompromised patients,” says Camille N. Kotton, MD, clinical director of the Transplant and Immunocompromised Host Infectious Disease Group at Massachusetts General Hospital in Boston. “In general, immunocompromised hosts tend to have lower immune response to vaccinations and so may need a second dose to achieve the most protection.”
The latest information available at press time is that the first H1N1 vaccine to be released to the general population will be an attenuated live virus vaccine. However, use of this type is not encouraged in immunosuppressed populations, another consideration for physicians.
Which Shots to Give?
“Most [rheumatic disease] patients are lumped together under the rubric of compromised host, and live virus vaccines are contraindicated in this group,” says Dr. Kotton. “Although the guidelines suggest immunocompromised patients should get the shots sooner rather than later, the small time differential is not likely worth the risk of administering a live virus vaccine.”
There are fairly good data suggesting that patients on immunosuppressant medications do receive benefit from the seasonal flu vaccine.
—Kathleen L. Sullivan, MD