Infection Screening and Vaccination of Adult and Pediatric Patients with Autoimmune Inflammatory Rheumatic Diseases: An Emirati Delphi Consensus.

ObjectivesThe aims of this study were to update the evidence on the incidence and prevalence rates of vaccine preventable infections (VPI) in patients with autoimmune inflammatory rheumatic diseases (AIIRD) and...

Background Despite the well-established fact of a high burden of infections among patients with autoimmune inflammatory rheumatic diseases (AIIRD)1, little evidence is available regarding the real incidence and prevalence of vaccine preventable infections (VPI) in this population. Objectives To update the evidence on the incidence and prevalence rates of VPI in patients with AIIRD and compare the data to the general population when available. Methods A systematic literature review was performed using Medline, Embase, and Cochrane library, from October 2009 to August 2018. Search terms were defined for AIIRD and VPI. Observational studies including cohort studies for incidence rates and cross-sectional studies for prevalence rates were included, as well as systematic reviews of cohort studies and meta-analyses. The primary outcome was the incidence or prevalence of VPI in the adult AIIRD population. Meta-analysis was performed when appropriate. Results The search identified 3876 records, out of which 63 met the inclusion criteria. Data on the following VPI rates was retrieved and analyzed: influenza (incidence; n=4), pneumococcal disease (incidence; n=7), hepatitis B virus (HBV) (incidence and prevalence; n=10), herpes zoster (HZ) (incidence; n=29), human papilloma virus (HPV) (incidence and prevalence; n=13). For influenza, limited data pointed to an increased incidence (409.33 vs 306.12 cases per 100,000 patient-years in patients with rheumatoid arthritis (RA) vs controls, respectively) and influenza-related complications in patients with AIIRD. Data on pneumococcal disease, available mainly for patients with systemic lupus erythematosus (SLE), showed a substantially increased risk in all age groups compared to controls (incidence rate ratio (IRR) 4.7, 95% confidence interval (CI) 3.7-6.0). For HZ, an increased risk was observed across all patients with AIIRD in comparison to the general population: pooled incidence rate ratio 2.4, 95% CI 2.05-2.76, with the highest incidence rate (IR) observed in inflammatory myositis (pooled IR 35.98, 95% CI 32.33-39.64), followed by SLE (pooled IR 18.87, 95% CI 8.7-29.64), and RA (pooled IR 11.64, 95% 9.37-13.91). Studies on HPV mainly investigated the SLE population in the Latin America and Asia: HPV pooled prevalence 26%, 95% CI 17%-36% and pooled prevalence ratio 1.58, 95% CI 0.74-3.36 in comparison with the general population. In RA, limited data showed a similar prevalence of HPV in patients and controls: pooled prevalence ratio 0.72, 95% CI 0.46-1.12. For hepatitis B virus, pooled prevalence of hepatitis B surface antigen in patients with AIIRD was similar to the general population, 3%, 95% CI 1%-5%. Conclusion Current evidence shows an increased risk of vaccine-preventable infections in patients with AIIRD, emphasizing that prevention of infections is essential in these patients.

ObjectivesTo develop EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in patients with autoimmune inflammatory rheumatic diseases (AIIRD).MethodsAn international Task Force (TF) (22 members/15 countries) formulated recommendations,...

ObjectivesA European League Against Rheumatism (EULAR) Task Force was established to update the recommendations for vaccination of patients with autoimmune inflammatory rheumatic diseases (AIIRD) published in 2011.MethodsFollowing the latest version...

Background:The 2019 EULAR recommendations on vaccination for adult patients with rheumatic immune-mediated inflammatory diseases (IMIDs) concluded that these patients are at increased risk of herpes zoster (HZ) compared to the...

This chapter addresses all important questions regarding vaccination of patients with autoimmune inflammatory rheumatic diseases (AIIRD). First, the incidence of vaccine-preventable infections in these patients is discussed. Pulmonary infections, including influenza and pneumococcal infection, occur more often in AIIRD patients; herpes zoster and human papillomavirus are also more frequent. The efficacy of vaccination for all European registered vaccines is discussed. Treatment with disease-modifying anti-rheumatic drugs (DMARDs) and biologicals (in particular TNFα‎-blocking agents) do not hamper, or only slightly hamper, the immune responses to most vaccines. Rituximab is an exception, severely reducing humoral responses following influenza and pneumococcal vaccination, at least during the first 6 months after administration. Safety of vaccination is an important issue in patients with autoimmune diseases, since increased disease activity of the underlying disease as a result of vaccination is theoretically possible. The available evidence is summarized, suggesting that vaccination is safe in AIIRD patients. Live vaccines, however, are contraindicated in immunosuppressed patients with AIIRD. Finally, the European League Against Rheumatism (EULAR) recommendations are highlighted, summarizing the 'do's' and 'don'ts' of vaccination in adults with AIIRD.

ObjectivesAs global vaccination campaigns against COVID-19 disease commence, vaccine safety needs to be closely assessed. The safety profile of mRNA-based vaccines in patients with autoimmune inflammatory rheumatic diseases (AIIRD) is unknown. The objective of this report is to raise awareness to reactivation of herpes zoster (HZ) following the BNT162b2 mRNA vaccination in patients with AIIRD.MethodsThe safety of the BNT162b2 mRNA vaccination was assessed in an observational study monitoring post-vaccination adverse effects in patients with AIIRD (n = 491) and controls (n = 99), conducted in two Rheumatology Departments in Israel.ResultsThe prevalence of HZ was 1.2% (n = 6) in patients with AIIRD compared with none in controls. Six female patients aged 49 ± 11 years with stable AIIRD: rheumatoid arthritis (n = 4), Sjogren’s syndrome (n = 1), and undifferentiated connective disease (n = 1), developed the first in a lifetime event of HZ within a short time after the first vaccine dose in 5 cases and after the second vaccine dose in one case. In the majority of cases, HZ infection was mild, except a case of HZ ophthalmicus, without corneal involvement, in RA patient treated with tofacitinib. There were no cases of disseminated HZ disease or postherpetic neuralgia. All but one patient received antiviral treatment with a resolution of HZ-related symptoms up to 6 weeks. Five patients completed the second vaccine dose without other adverse effects.ConclusionEpidemiologic studies on the safety of the mRNA-based COVID-19 vaccines in patients with AIIRD are needed to clarify the association between the BNT162b2 mRNA vaccination and reactivation of zoster.

BackgroundA higher incidence of herpes zoster (HZ) was found in people with decreased cell-mediated immunity. However, the relationship between cellular immunity and HZ infection in patients with autoimmune inflammatory rheumatic diseases (AIRD) remains elusive.ObjectiveTo investigate the role of CD4/CD8 ratio in patients with AIRD and HZ.MethodsThis case-control study compared AIRD patients with and without HZ. We chose 70 AIRD patients with HZ as the experimental group and 140 AIRD patients without HZ as the control group. The clinical and laboratory findings were assessed in each trial participant.ResultsThe CD4/CD8 ratio (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.10–0.49) was independently associated with the occurrence of HZ after adjusting for various confounders. Nonlinear analysis has unveiled a more profound nonlinear relationship between the CD4/CD8 ratio and the occurrence of HZ in patients with AIRD. The OR of HZ increased with a decreasing CD4/CD8 ratio before the turning point of 2. The adjusted regression coefficient was 0.14 (95% CI, 0.05–0.37, p<0.0001) for CD4/CD8 ratio less than 2.ConclusionThe CD4/CD8 ratio was expected to be a very promising quantitative biomarker for predicting the risk of developing HZ in patients with AIRD.

Background. Patients suffering from autoimmune inflammatory rheumatic diseases (AIIRD) are exposed to a higher risk of infections due to both their background and the immunosuppressant and immunomodulatory medications. This brings us to the question of what we can do to ensure the protection of our patients. And one of the answers should be vaccination. Methods. We performed a literature search in electronic database (PubMed) using keywords related to vaccination and rheumatic diseases. Also, relevant information concerning vaccination recommendations were collected form a website search of specific organizations dealing with management of autoimmune rheumatic disease in various countries. Results. Patients with AIIRD are at increased risk of infections and even if some of them could be prevented in part by vaccines, the rates of vaccination in this category of patients remains low. The 2015 American College of Rheumatology (ACR) guideline for the treatment of rheumatoid arthritis recommends the administration of influenza, pneumococcal, hepatitis B, human papilloma and shingles vaccines in patients requiring disease modifying antirheumatic drugs (DMARDs) or biologics, the first three being strongly recommended in patients with rheumatoid arthritis. The guideline does not recommend the administration of life attenuated vaccines, such as shingles vaccine, in patients under biologics. These are consistent with the recommendations from the Centers for Disease Control and Prevention (CDC) for vaccination of immunocompromised patients. In cases where live attenuated vaccines need to be used, the immunosuppressive therapy should be delayed by at least 4 weeks following vaccination. Conclusions. Despite important differences between different countries, there is a general consensus on the importance of immunizing AIIRD patients through vaccination. The most widely recommended vaccination regimens refer to influenza and pneumococcal vaccines, but other specific vaccines such as hepatitis B, human papilloma virus, herpes zoster, meningococcal, and Haemophilus influenzae type b should also be considered.

Background: Vaccination rates are known to be low in patients with autoimmune inflammatory rheumatic diseases (AIIRD). We therefore aimed to determine current vaccination rates against influenza, Streptococcus pneumoniae and herpes zoster in a cohort of patients with AIIRD in Germany. Methods: Consecutive adult patients with an AIIRD were recruited from our outpatient clinic during their regular consultations. The individual vaccination status regarding influenza, Streptococcus pneumoniae and herpes zoster was obtained by reviewing the vaccination documents. Results: A total of 222 AIIRD patients (mean age 62.9 ± 13.9 years) were included. In total, 68.5% were vaccinated against influenza, 34.7% against Streptococcus pneumoniae and 13.1% against herpes zoster (HZ). The pneumococcal vaccination was outdated in 29.4% of the vaccinated patients. Vaccination rates were significantly higher in patients ≥60 years old (odds ratio (OR) 2.167, 95% confidence interval (CI) 1.213–3.870, p = 0.008 for influenza, OR 4.639, 95% CI 2.555–8.422, p < 0.0001 for pneumococcal and OR 6.059, 95% CI 1.772–20.712, p = 0.001 for HZ vaccination). Ages > 60 years, female sex, glucocorticoid use and influenza vaccination were all independently associated with a pneumococcal vaccination. Regarding influenza vaccination, only a positive pneumococcal vaccination history remained independently associated. In patients with HZ vaccination, glucocorticoid use and a preceding pneumococcal vaccination were independently associated with HZ protection. Conclusions: The frequencies of vaccinations against influenza, Streptococcus pneumoniae and HZ have increased during recent years. While this can be partly explained by continuous efforts in patient education during the outpatient visits, the COVID-19 pandemic might also have contributed. Nevertheless, the persistently high incidence and mortality of these preventable diseases in patients with AIIRDs mandates further efforts to increase vaccination coverage, particularly in SLE patients.

Background:Patients with autoimmune inflammatory rheumatic diseases (AIIRD) have a higher burden of infectious diseases compared to the general population. This could be explained by the disturbances in their immune system response, comorbidities and immunosuppressive treatment.Vaccination is the most effective measure to prevent infections.Objectives:To describe a cohort of patients with AIIRD referred to the infectious disease´s unit according to the vaccination protocol.Methods:Restrospective and descriptive study of a cohort of 286 patients with AIIRD who were evaluated in the rheumatology service of a tertiary hospital in Barcelona and referred to the infectious disease´s unit according to the vaccination protocol among 1 year,between January 1rst December 31st, 2019. The vaccination protocol included serologies of human immunodeficiency virus,hepatitis A,B and C, varicella zoster,tuberculosis,measles,mumps and rubella virus.The recommended vaccines were H.influenzae b,S.pneumonia,influenza,hepatitis A and B(immunity absence),meningococcus c,tetanus – diphtheria (low antigenic load),poliomyelitis and human papillomavirus (not vaccinated).The patients included were diagnosed with a rheumatologic condition under immunosuppressive therapy. Demographic variables,diagnosis,treatment,vaccines administered,infections and adverse effects were collected.Results:Of 286 patients reviewed the mean age was 61, 4 (±14.4) years. The characteristics of the cohort are shown in Table 1. Most of the patients used csDMARDs 149 (52.1%), 77(26.9%) patients used combined treatment. Measles and rubella are part of the triple virus vaccines included in the systematic Spanish vaccination schedule, in our cohort 20 (7%) patients had negative serologies for measles and 26 (9%) for rubella. 57 (20%) patients had latent TB with positive Quantiferon.Forty-one (14.3%) were vaccinated before receiving immunosuppressive treatment. The less administered vaccine was influenza with 44.9% (vaccination rate in Spain in healthy population, in 2019-2020 was 51.2%).No serious adverse effects were reported in relation to the vaccination. The infectious complications during the follow-up period were bronchopneumonia in a patient with RA treated with certolizumab (1), herpes zoster infection in RA on adalimumab(1), recurrent otitis in RA on adalimumab(1), mycobacterium avium infection in RA on etanercept(1), TB reactivation in RA with GCs and csDMARDs(1) and Papilloma virus infection in SpA on ustekinumab (1).Table 1.CHARACTERISTICS OF COHORT OF PATIENTSSex n % (women/men)193/93 (67,5/32,5)Age, years ± DE61.4 ± 14.4Diagnoses AIIRD, n (%)Rheumatoid arthritis n (%)164 (57.3)Systemic lupus erythematosus n (%)6 (2.1)Sjögren´s syndrome n (%)9 (3.1)Systemic sclerosis n (%)1 (0.35)Inflammatory myopathie n (%)5 (1.7)Vasculitis n (%)36 (12.6)Polymyalgia rheumatica n (%)4 (1.4)Spondyloarthropathy n (%)46 (16.1)Others n (%)15 (5.2)Treatment AIIRDGCs n (%)116 (40.7)csDMARDs n (%)149 (52.1)bDMARDs n (%)80 (27.8)tsDMARDs n (%)7 (2.4)Others1 n (%)12 (4.2)GCs + csDMARDs n (%)59 (21)GCs + bDMARDs n (%)14 (4.9)GCs + csDMARDs + bDMARDs n (%)4 (1.4)VaccinesPCV 13 n (%)283 (99)PPSV23 n (%)265 (93)HiB n (%)265 (93)NM n (%)247 (86.7)Influenza n (%)128 (44.9)HBV n (%)121 (42.3)Vaccination before IS n (%)41 (14.3)Vaccination with IS n (%)244 (85.3)Other: Behcet,Adult Stills,Relapsing polychondritis,IGg4 related disease,SarcoidosisOthers1: Mycophenolic acid,cyclosporine and tacrolimusConclusion:In our cohort, the vaccination protocol proved to be a good tool to improve the vaccination rate of rheumatological patients, despite this, the vaccination of Hepatitis B and specially of influenza, continues to have a lower prevalence to general population.The vaccines were effective since none of the preventable infections occurred during follow up, despite the use of an immunosuppressant. Vaccination showed a good safety profile, without reported serious adverse effects or worsening of the underlying disease.Disclosure of Interests:None declared

This chapter addresses all important questions regarding vaccination of patients with autoimmune inflammatory rheumatic diseases (AIIRD). First, the incidence of vaccine-preventable infections in these patients is discussed. Pulmonary infections, including influenza and pneumococcal infection, occur more often in AIIRD patients; herpes zoster and human papillomavirus are also more frequent. The efficacy of vaccination for all European registered vaccines is discussed. Treatment with disease-modifying anti-rheumatic drugs (DMARDs) and biologicals (in particular TNFα‎‎-blocking agents) do not hamper, or only slightly hamper, the immune responses to most vaccines. Rituximab is an exception, severely reducing humoral responses following influenza and pneumococcal vaccination, at least during the first 6 months after administration. Safety of vaccination is an important issue in patients with autoimmune diseases, since increased disease activity of the underlying disease as a result of vaccination is theoretically possible. The available evidence is summarized, suggesting that vaccination is safe in AIIRD patients. Live vaccines, however, are contraindicated in immunosuppressed patients with AIIRD. Finally, the European League Against Rheumatism (EULAR) recommendations are highlighted, summarizing the ’do’s’ and ’don’ts’ of vaccination in adults with AIIRD.

To evaluate vaccination rates and identify factors associated with vaccine uptake among patients with autoimmune inflammatory rheumatic diseases (AIRD) in Kanagawa Prefecture, Japan. An anonymous survey was conducted between January and May 2023 using Google Forms™. Adult AIRD patients and rheumatologists were asked about demographics, disease characteristics, vaccination status, and attitudes towards vaccination. Logistic regression and random forest analyses were used to identify factors influencing vaccination rates. A total of 1 637 AIRD patients responded. Vaccination rates were as follows: herpes zoster 8.8%, influenza 86.7%, pneumococcus 29.7%, human papillomavirus 4.3%, hepatitis B virus 8.7%, and severe acute respiratory syndrome corona virus-2 92.2%. Physician recommendations were significantly associated with higher vaccination rates. Although knowledge of vaccine efficacy correlated with increased uptake, it did not fully alleviate vaccine hesitancy. Major barriers included concerns about adverse effects and lack of sufficient information. Physician recommendations and providing comprehensive vaccine information are essential for improving vaccination rates among AIRD patients. Addressing concerns about vaccine safety and efficacy through targeted educational interventions and communication strategies is crucial to enhancing vaccine uptake.

Background:Women with autoimmune inflammatory rheumatic diseases (AIIRDs) may be more vulnerable to human papillomavirus (HPV) infection and HPV-related cervical cancers [1,2]. However, the HPV test and HPV vaccination rate was...

To update the European League Against Rheumatism (EULAR) recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD) published in 2011. Four systematic literature reviews were performed regarding...