Orlando, FL—Patients often come into the rheumatology setting as candidates for vaccines. Protecting them from infection via vaccination before they receive immunosuppressive therapy should be a priority, advises Elizabeth Kirchner, CNP.
Vaccine status should be assessed at the first patient encounter, she said at the 2015 Annual Conference of the Rheumatology Nurses Society.1 Some myths about vaccines may need to be addressed with patients before they will accept vaccinations.
Explain to patients that, even after receiving an influenza vaccination, if they encounter the flu virus, their body will mount an immune response and they might experience low-grade fever, headache, and body aches. Also educate them that protection does not occur immediately after vaccination.
A killed/inactivated vaccine is more stable and safer than live vaccines, but the response to killed/inactivated vaccines is typically weaker than with live vaccines. Examples of killed/inactivated vaccines encountered in an adult rheumatology practice include vaccines against tetanus, diphtheria, and/or pertussis (Td, TdaP); hepatitis A/B; influenza; pneumococcal; human papilloma virus (HPV); meningococcal conjugate; anthrax; and polio.
Live/attenuated vaccines contain a live version of the living microbe that has been weakened in the lab and “are the closest thing to a natural infection,” said Kirchner. Examples are varicella, intranasal influenza, measles/mumps/rubella (MMR), adenovirus, yellow fever, rotavirus, and oral polio.
In 2011, the European League Against Rheumatism (EULAR) issued updated vaccination guidelines.2 One recommendation is for assessment of vaccine status at the first encounter. “In rheumatology, we often have a very narrow window of when we can give vaccines safely or give them to the best effect,” said Kirchner, a certified nurse practitioner in the Department of Rheumatologic and Immunologic Disease at the Cleveland Clinic. “When patients come in to us, almost all of them have something wrong with their immune system; they have an autoimmune disease. What we’re going to do is immunosuppress them [with treatment].”
EULAR also recommends that administration of vaccines occur when disease is stable. Patients do not have to be in disease remission to be vaccinated, she said.
“It’s okay to vaccinate with killed vaccines if a patient is on DMARDs [disease-modifying antirheumatic drugs] or anti–tumor necrosis factor inhibitors, but vaccinate before starting B-cell depletion,” Kirchner said.
Rituximab depletes circulating B cells. “There’s no point vaccinating the day somebody is getting rituximab, because there are no B cells there to respond to, and there won’t be for a while,” she said. “Try to vaccinate at least a month before patients start rituximab. It doesn’t matter if you kill off all the circulating B cells; the memory is there, and they can still have a response down the road if they become exposed to that pathogen. If they’ve already started rituximab, then try to catch them either in the middle of the rituximab cycle or 3 months or 2 months before their next rituximab.”
Herpes zoster vaccine (HZV) is a live attenuated vaccine that decreases the risk of developing zoster by 51% and the risk of postherpetic neuralgia by 67%.3 The Advisory Committee on Immunization Practices recommends a dose of HZV for all adults ≥60 years unless they have contraindications. In a rheumatology practice, contraindications would be treatment with high-dose prednisone (≥20 mg/day) or biologic agents.
A new shingles vaccine not yet licensed in the United States is a subunit vaccine (not live), “and that means we’re going to be able to give shingles vaccine to all of our patients, no matter what medicine they’re on,” Kirchner said. In a study of 15,411 older adults over a 3-year period, the number of shingles cases reported was 210 in the placebo group versus 6 in the group receiving active vaccine, for 97% efficacy.4
- Kirchner E. Vaccines and our patients. Presented at: 2015 Annual Conference of the Rheumatology Nurses Society; August 6-8, 2015; Orlando, FL.
- van Assen S, Agmon-Levin N, Elkayam O, et al. EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2011;70:414-422.
- Harpaz R, Ortega-Sanchez IR, Seward JF. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008;57(RR-5):1-30.
- Lal H, Cunningham AL, Godeaux O, et al; for the ZOE-50 Study Group. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med. 2015;372(22):2087-2096.