Specialists share equal responsibility with primary care providers for ensuring that immunocompromised patients are vaccinated, according to the recent guidelines issued by the Infectious Diseases Society of America.
The 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host states that specialists are in a “pivotal position to ensure vaccination by administering vaccines or providing specific advice to patients and primary care providers.1 Specialists should educate patients and members of their household on the importance of vaccination of household members for the protection of the immunocompromised patient.”
Leonard Calabrese, DO, professor of medicine in the department of rheumatic and immunologic diseases at Cleveland Clinic Lerner College of Medicine, said that immunocompromised patients often are not vaccinated. “There is a gaping hole in immunizations being administered,” he said. Some rheumatologists think immunizations lie outside the scope of their practice, given that vaccines can be expensive or difficult to store. “We do not have a systematic approach to vaccines in our profession that allows for optimal vaccine administration,” Dr. Calabrese said.
Gil Melmed, MD, MS, director of clinical inflammatory bowel disease at Cedars-Sinai Medical Center in Los Angeles, agreed. “Specialists are the ones that call the shots for the therapies that suppress the immune system, but often we, as specialist communities, may deflect the responsibility for vaccinations to primary care providers. We have learned from study after study from around the world that patients in specialty care clinics don’t get the vaccinations that they should be getting.”
There are numerous reasons why primary care physicians may not be vaccinating patients who are being treated with immunosuppressive therapy. Some are unfamiliar with newer therapies, such as biologics, and others think that vaccines are unsafe or ineffective for patients who are immunocompromised. Patients on immunosuppressive therapy, however, have a lot to gain with appropriate vaccination. These patients are predisposed to an increased risk or severity of vaccine-preventable infection, and they may have greater exposure to pathogens because of their more frequent contact with medical facilities, the IDSA document states.
Although the response rates to certain vaccines may be somewhat blunted when patients are on immunosuppressive therapies, particularly such immunomodulators as methotrexate or other DMARDs, that should not be used as an excuse to skip vaccinations, Dr. Melmed said. “These patients absolutely should be vaccinated according to recommended guidelines, [because] some protection is better than none.”
Additionally, concerns that a vaccine may trigger a disease flare in patients with chronic inflammatory diseases seem unfounded. According to the IDSA guidelines, there is a preponderance of clinical evidence that vaccines are not important disease flare triggers and should not be withheld for that reason.
The ACR’s 2012 recommendations for use of DMARDs and biologic agents in treatment of rheumatoid arthritis highlighted the importance of immunizations and noted the increasing awareness of risk of preventable diseases, such as influenza and pneumonia.2 The ACR’s recommendations, such as these released by the IDSA, are in accordance with guidance from the Centers for Disease Control and Prevention.
The IDSA guideline recommends several vaccines for patients with chronic inflammatory diseases:
- A combination of two vaccines is recommended against pneumonia for immunosuppressed patients: PCV13, the pneumococcal conjugate vaccine, can be administered to patients being treated with immunosuppression. At least eight weeks later, those patients should receive PPSV23, the pneumovax, followed by a second dose of PPSV23 in five years. The newer vaccine, PCV13, seems to provide greater protection against the 13 most common or virulent strains, and optimal protection is afforded with administration of both PCV13 and then PPSV23. This recommendation that the PCV13 vaccine for adults is approved for use in combination with PPSV23 is new and thus was not included in the ACR document.
- Inactivated vaccines, including influenza vaccine, can be given annually to those either being treated or about to be treated with immunosuppressive agents.
- The (live virus) varicella (VAR) vaccine can be given to patients without evidence of varicella immunity four weeks or more prior to initiation of immunosuppression. The vaccine can be considered for those who are already being treated with long-term, low-level immunosuppression. (The document defines what is meant by low- and high-level immunosuppression.)
- The zoster (ZOS) vaccine should be given to patients 60 years or older prior to initiation of immunosuppressive therapy or to those already being treated with low-dose immunosuppression. Patients 50–59 years old who are varicella positive prior to initiation of immunosuppression or who are being treated with low-dose immunosuppression can also receive the vaccine.
- The hepatitis B vaccine should not be withheld because of concerns about exacerbation of chronic immune-mediated or inflammatory illness.
Dr. Melmed noted that the IDSA guidelines reflect a “softening position” on administration of some live vaccines (varicella and zoster) that now can be given in certain circumstances, even if the patient is on immunosuppressive therapy.
“This is an evolving position which recognizes that we should not be completely dogmatic about this. We have to recognize that some infections, such as shingles or chicken pox, can be devastating to patients who are on immunosuppressive therapy and that the benefits of vaccination outweigh the theoretical risks of these specific vaccines.
“There is no strong evidence to say that the vaccines cause shingles if you get them while immunocompromised; on the other hand, there is mounting evidence to suggest that patients are protected if on immunosuppression while getting these live virus vaccines,” he added.
Some live vaccines, however, are not recommended for patients with chronic inflammatory disease who are on maintenance immunosuppression. These include the live attenuated influenza vaccine (LAIV) and the measles, mumps, rubella vaccine (MMR) in patients receiving low-level and high-level immunosuppression, as well as the measles, mumps, rubella, varicella (MMRV) vaccine in those receiving low- or high-level immunosuppression. The yellow fever vaccine is also strictly contraindicated in immunosuppressed individuals, and these patients should ideally avoid travel in areas where the disease is endemic.
Vaccination of Household Members
The IDSA recommends that specialists help their patients limit exposure to vaccine-preventable infections by ensuring that household members are kept up to date on vaccinations. Recommended vaccines include the annual influenza vaccine, with specific recommendations given about when to recommend the nonlive vs. the live vaccine, and other vaccinations including MMR, VAR and ZOS. The oral polio vaccine, however, should not be given to people who live with an immunocompromised person.
Other caveats are given. For example, an immunocompromised person on therapy should avoid contact with a household member who develops a rash after the VAR or ZOS vaccine until the lesions go away. Highly immunocompromised patients should not handle the diapers of an infant who has been vaccinated with the rotavirus vaccine for four weeks after vaccination because live virus may be shed in the stool for two to four weeks.
Dr. Calabrese recommends “significant conversation within the rheumatology community” about the low rate of vaccinations among immunocompromised patients. “Rheumatologists are confused, and so are most primary care physicians who see these patients taking drugs that they are unfamiliar with, such as biologics. We need to have some fundamental changes in the systems that can contribute to vaccination. Recognizing the importance of this shared responsibility is the best starting point, and this document takes on the issue forthrightly,” he said.
Kathy Holliman is a medical journalist based in Massachusetts.
Vaccines to avoid
- For patients with chronic inflammatory disease who are on maintenance immunosuppression—the live attenuated influenza vaccine (LAIV);
- For patients receiving low- and high-level immunosuppression—the measles, mumps, rubella vaccine (MMR);
- For patients receiving low- or high-level immunosuppression—measles, mumps, rubella, varicella (MMRV) vaccine; and
- For immunosuppressed individuals—yellow fever vaccine.
- Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58:309–318.
- Singh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis. Arthritis Care Res. 2012;64:625–639.