Patients with rheumatic diseases and those in immunocompromised conditions can still be vaccinated against infection although the immune response of the organism is compromised. In general, live bacterial (viral) vaccines are prohibited in these patients, but inactivated vaccines can still be used. Although the response of these patients to vaccines is not ideal, and there are some scattered reports of rheumatic diseases induced by vaccination or aggravation of existing rheumatic diseases, the relationship between vaccines and rheumatic diseases is inconclusive, so patients with rheumatic diseases can use inactivated vaccines.
I. Influenza vaccine and pneumococcal polysaccharide vaccine
Influenza virus infection in immunocompromised patients can have serious consequences once it is contracted, or secondary bacterial infection can have serious consequences. Similarly, pneumococcal infections can cause complications such as sepsis, pneumonia, and meningitis, and are an important cause of death in immunocompromised patients. Both vaccines are safe and effective in patients with rheumatoid arthritis and lupus, but immunization is less effective than in healthy individuals.
The 2008 American College of Rheumatology guidelines recommend inactivated vaccines for rheumatoid patients on leflunomide, methotrexate, or lutensulfapyridine and avoid live vaccines. Influenza vaccine should be given once a year, and live attenuated vaccine should not be given through the nasal mucosa. Pneumococcal polysaccharide vaccine should be given once every 2-3 years.
II. Hepatitis B vaccine
Hepatitis B virus is an important cause of chronic liver disease. Patients with immunocompromised rheumatic diseases are more likely to develop chronic carrier status after infection, leading to chronic active hepatitis, end-stage liver disease and liver cancer.
There are no guidelines for the use of hepatitis B vaccine in patients with rheumatic diseases. Hepatitis B vaccine can cause exacerbation of lupus lipofuscinosis, but prospective studies have shown that hepatitis B vaccine is safe in patients with lupus in remission. Because it is not a live vaccine, it is safe for patients with immunocompromised rheumatic diseases, but it is less effective.
C. Vaccine
There are no guidelines for its use in patients with immunocompromised rheumatic diseases, but it should be safe because it is an inactivated vaccine or a toxoid vaccine.
In adults who have not received this vaccine, 3 doses (0, 4-8 weeks and 6-12 months) may be administered; after trauma, one booster dose should be given if the vaccine was administered as a child but it has been more than 5 years; if it is not clear whether the vaccine was administered, one dose each of tetanus antitoxoid and vaccine should be administered simultaneously. The vaccine has been reported to cause reactive arthritis in some cases, but it is inconclusive whether it causes autoimmune disease.
Rabies vaccine
The rabies vaccine currently used is inactivated and has a reduced chance of causing encephalitis. In patients with rheumatic diseases receiving hormones and other immunosuppressive drugs, the antibody titer obtained by intradermal vaccination is low, so intramuscular vaccination is recommended.
V. Haemophilus influenzae type B vaccine
Patients who are immunocompromised in adulthood may be considered for vaccination if they have not been vaccinated.
Meningococcal vaccine
Because patients with diffuse connective tissue diseases such as lupus have functional absence of spleen and complement C3 deficiency, they should receive meningococcal vaccine.
VII. Hepatitis A vaccine
There are no guidelines for the use of hepatitis A vaccine in patients with rheumatic diseases. Inactivated vaccines are available and are safe for immunocompromised patients, but are less effective.
VIII. Herpes zoster vaccine
Patients with rheumatic diseases have a higher chance of developing herpes zoster, and once present, the rash is often severe and difficult to cure, with an increased chance of visceral dissemination or death. 2006 saw the introduction of a low-temperature freeze-dried live attenuated vaccine, which is highly effective and suitable for immunocompetent patients, but is not recommended for patients who are immunocompromised, taking immunosuppressive drugs, or have acute herpes zoster or postherpetic neuralgia.
The vaccine is also available for rheumatoid patients over 60 years of age who are taking low-dose MTX (≤ 0.4 mg/kg/wk) or hormones (≤ 20 mg/d for < 2 weeks) or emmaline (≤ 3 mg/kg/d ). It is not recommended for patients with other connective tissue diseases, and if vaccination is to be administered, it should be done 2 weeks prior to the use of immunosuppressive drugs.
In addition, patients with rheumatic diseases should avoid contact with people who have received a particular vaccine or have developed symptoms. For example, if a healthy person who has received chickenpox develops a rash, it is easily transmitted to patients with rheumatic diseases, and direct contact with them should be avoided until the rash disappears. Patients with rheumatic diseases should also avoid close contact with people who have received oral polio vaccine and smallpox vaccine, as these vaccines may lead to the spread of the virus.