Immunizations in Immunocomprised Patients

SAN FRANCISCO—Rheumatologists face several questions when choosing appropriate vaccinations for their patients with rheumatoid arthritis (RA) and other diseases such as lupus that may be treated with immunosuppressive agents. Some, in fact, may wonder whether vaccinations should be given at all because their patients are likely to have a reduced immunologic response. Camille N. Kotton, MD, adopts a glass-half-full approach to influenza and pneumonia vaccinations in this vulnerable population. “As someone who deals with very ill immunocompromised patients, I feel strongly that some immunologic protection is better than none,” she asserted in the session, “Immunization in the Immunosuppressed Host,” held at the 2008 ACR/ARHP Annual Scientific Meeting.

Dr. Kotton is clinical director of the Transplant and Immunocompromised Host Infectious Diseases Group at Massachusetts General Hospital, Boston; assistant professor at Harvard Medical School, Boston; and president of the Transplantation Infectious Diseases Section at the Transplantation Society. She explained that her stance on influenza and pneumococcus vaccination has been informed by her experience at Massachusetts General, where vaccination of immunocompromised transplant recipients on the transplant service has become routine. “You may not always be able to prevent disease,” she noted, “but the disease we do see may be significantly attenuated.”

More Vulnerable

Patients with rheumatic diseases have twice the risk of acquiring infection than those in the general population.¹ However, the question often arises as to whether vaccines might precipitate or worsen rheumatologic disease. Dr. Kotton pointed out that the jury is still out on this question: Most of the arguments against the use of vaccines are based on case reports, which are inadequate to establish a link between immunizations and worsening of preexisting rheumatologic disease. In addition, possible mechanisms of viral-induced autoimmunity (e.g., change in the host antigen and expression of HLA antigen) have yet to establish how vaccinations could trigger autoimmunity.

In the meantime, some guidance is available from several studies that show that influenza and pneumococcus vaccines are basically safe in patients with rheumatic disease. Dr. Kotton summarized several investigations that have demonstrated differing seroconversion rates in response to influenza, pneumococcus, and tetanus vaccines in RA and systemic lupus erythematosus patient populations. Again, Dr. Kotton repeated her assertion that some protection is better than none. She also suggested that clinicians might consider giving the flu vaccine later in the fall (closer to November) so that patients would have greater immunity coverage for the duration of the flu season, which tends to hit in December.