Vaccinations and Lupus: An Update of What You Should Know

Adapted from a presentation at the SLE Workshop at Hospital for Special Surgery


Barry D. Brause, MD

Barry D. Brause, MD

Attending Physician, Hospital for Special Surgery
Director of Infectious Diseases, Hospital for Special Surgery
Professor of Clinical Medicine, Weill Cornell Medical College

Introduction

During this session, Dr. Barry Brause, Director of Infectious Diseases at Hospital for Special Surgery, presented an update on infectious disease prevention today. He reviewed various infectious diseases covering how they are spread, the different types of vaccinations available, and his recommendations for protecting yourself from infectious diseases.

Higher Risk of Infection in Patients with Rheumatic Disease

Dr. Brause began his presentation by describing how patients with rheumatic diseases, such as lupus, have a higher risk of infection. The increased risk is related to the suppression of the immune system, also called immunosuppression, due to the underlying disease and the treatment associated. Treatments that suppress the immune system may include the following:

  • Corticosteroids
  • Disease-modifying anti-rheumatic drugs (DMARDS), for example, methotrexate, leflunomide (Arava), azathioprine (Imuran), cyclosporine.
  • Biologic agents (ex. Anti-TNF agents such as etanercept (Enbrel) or adalimumab (Humira)

Immunosuppressive drugs for SLE specifically include the following:

  • Azathioprine (Imuran, Arasan)
  • Belimumab (Benlysta) – biologic agent
  • Corticosteroids (prednisone)
  • Cyclophosphamide (Cytoxan)
  • Methotrexate (Trexall, Rheumatrex)
  • Mycophenolate (CellCept, Myfortic)
  • Rituximab (Rituxan) – biologic agent

Biologic agents are distinguished from other immunosuppressives in that they are produced by living systems, such as bacteria or plant or animal cells. As soon as one starts to modify their immune system through these drugs, one modifies the immune system’s ability to fight off and prevent infection.

Immunosuppressive Drug therapy can increase the risk of infection, including:

  • Bacterial sepsis
  • Mycobacterial-TB infection recrudescence
  • Fungal infection / re-activation (Histoplasmosis, Coccidiodomycosis,Blastomycosis, Aspergillus, Candida)
  • Viral re-activation e.g.Varicella-Zoster virus (shingles) or worsening of a chronic viral infections, e.g. hepatitis B infection

In the event that a patient acquires a serious infection while on biologic agent therapy, the therapy is suspended. The patient may return to the biologic agent therapy once the infection is under control, if felt appropriate by the prescriber.

Similarly, where there is risk of surgical site infection, some immunosuppressive agents, such as biological agent therapy, may be suspended before or after surgical procedures to reduce the risk of infection. The patient resumes therapy after the surgical site has healed.

Vaccinations in Rheumatic Diseases

There is no evidence that vaccination causes flaring of autoimmune disease commonly, specifically in RA and SLE with:

  • Pneumococcal vaccine (killed)
  • Influenza vaccine (killed)

Both of these vaccines are strongly indicated in inflammatory rheumatic diseases due to disease-related increased morbidity and mortality from respiratory infection. Tdap (tetanus, diphtheria and pertussis (whooping cough)) vaccine is routinely given once in adulthood, and is helpful in patients taking immunosuppressive agents. 

For those with SLE, vaccinations do not commonly make SLE more active. Dr. Brause recommended that patients get vaccinated when they are not experiencing an active lupus flare. He strongly advised against getting vaccinated when there is active nephritis (kidney inflammation). Uncommonly, HBV, HPV, and Norwalk agent vaccines may induce disease flares.

According to Dr. Brause, killed vaccines - vaccines that do not have any live components in them at all - are safe and effective. Specifically, pneumococcal, influenza, and Hepatitis B vaccines are recommended by the American College of Rheumatology.

Live vaccines, however, are not recommended due to the increased risk of infection from the vaccine. They should generally be avoided. In most cases, there are suitable killed vaccines that may take the place of live vaccines.

Live vaccines to be generally avoided include the following (would need to have discussion with physician caring for your lupus before considering):

  • Measles, Mumps, Rubella, Yellow Fever
  • Varicella, Herpes zoster (Zostavax),
  • Live attenuated Influenza vaccine (LAIV); however, a killed vaccine is available
  • Typhoid (oral, Ty21a); however, a killed vaccine is available
  • Polio (oral, Sabin); however, a killed vaccine is available

Types of Infectious Diseases and Vaccines Available

Pneumococcal Infections

Streptococcus pneumonia (pneumococcus) is the leading cause of vaccine-preventable illness and death in the US. Pneumococcal Infections can cause pneumonia, blood infections, meningitis and other respiratory infections. Pneumococcal infections are transmitted from person to person by respiratory droplets, as can be spread by a cough. Those who are at greater risk include, those 65 years old and older, people with heart or lung disease, asthma, sickle cell disease, diabetes, smokers, alcoholics, cirrhosis, cerebrospinal fluid (CSF) fluid leaks, cochlear implants, lymphoma, leukemia, kidney failure, HIV infection, damaged or no spleen, and immunosuppressive diseases and treatment.

Types of Pneumococcal Vaccines

Pneumococcal Polysaccharide Vaccine (PPSV23) - is the older of the two vaccines currently available.

  • Dosage Information:
    • Receive the vaccine when you develop one of the predisposing conditions
      Receive a second dose 5 years later for some conditions. OR
    • Receive a second dose when you are over 65 years old if your first dose was at least 5 years earlier.
    • If you receive the vaccine only because you are over 65 years old, you only get one dose.
  • Side Effects:
    • About 50% of patients experience redness or pain at injection site
    • Muscle aches can occur
    • < 1 % have more serious local reactions or allergic reactions

Pneumococcal Conjugate Vaccine (PCV13) (Prevnar -13) – is a recently released vaccine designed to give more immunity and stronger antibodies than the PPSV23 vaccine, but it has a more narrow range of strains.

  • Dosage Information:
    • Receive a single dose of this vaccine when you develop one of the predisposing conditions (but not at the same time as the PPSV23 vaccine).
    • The timing of the dose should be discussed with your doctor.
  • Side Effects:
    • Redness, pain, swelling at injection site, fever, chills, headache, fatigue, muscle aches

Influenza

Influenza is an unpredictable respiratory virus. It has the capacity to cause a large amount of inflammation of the larynx, trachea and bronchi with mucosal edema. It can damage and weaken the cells lining your respiratory tract, so they will not protect you to the same degree. This creates greater risk of developing influenza pneumonia and bacterial pneumonia.

Complications

Influenza can lead to further complications including:

  • Primary influenzal viral pneumonia
  • Bacterial superinfection pneumonia
  • Exacerbation of chronic pulmonary disease

Uncommon complications include: myositis, myopericarditis, pericarditis, Guillain-Barré syndrome, Reye’s syndrome, encephalopathy, and transverse myelitis.

Target Groups

People who have a higher priority to receive influenza vaccine include:

  • Pregnant women
  • Persons providing care for infants aged less than 6 months of age
  • Healthcare emergency medical services personnel who have direct contact with patients or infectious material
  • Children aged 6 months - 4 years
  • Adults > 65 years old
  • Persons who have medical conditions which place them at higher risk for influenza-related complications such as:
    • people with neurologic disorders, asthma, chronic lung disease
    • heart disease, blood disorders
    • diabetes, kidney or liver disease metabolic disorders or obesity
    • weakened immune systems or on chronic steroid or other immunosuppressive therapy

Transmission

Influenza may be transmitted through saliva, nasal secretions and feces. Sneeze and cough particles can travel up to three feet. An infected person is contagious 24 hours prior to and up to seven days after symptoms of onset of the disease. Viruses can also continue to live days to weeks on dry surfaces. A person is most likely to be exposed through touching a contaminated surface and then touching one’s nose, eyes or mouth.

Prevention

Transmission of influenza can be prevented by thorough and frequent hand-washing and coughing into a barrier such as a tissue or elbow. One should stay informed about flu season, avoid touching eyes, nose and mouth, and avoid close contact with those who are infected, even if that person is on anti-viral therapy, and should stay home if ill. Lastly, one can get vaccinated!

Side Effects of Influenza Vaccines:

  • Pain and inflammation at injection site
  • 5% experience fever and 3-12% experience malaise
  • 2-9% experience myalgias (muscle pain) and 5-6% experience arthralgias (joint pain)
  • These side effects can begin 6 hours after vaccination and can persist for 2 days [Resolve with aspirin, Tylenol, NSAIDs (such as ibuprofen)]
  • Allergies such as hives may occur, but these reactions are rare unless you are allergic to eggs
  • Guillain-Barré syndrome may occur, but the incidence is very low

Hepatitis B Virus (HBV) Infection Risks with Biologic Agents

Patients should be screened for viral hepatitis before biologic agents are started. This is a routine practice. In patients with Hepatitis B, treatment with biologic agents may increase viral growth, worsening the disease. Therefore, biologic drugs should be avoided until the Hepatitis B is being managed, and only with approval by a specialist in hepatitis. If there is a possibility that a patient might contract Hepatitis B, the patient should be vaccinated. There is an effective non-live vaccine available.

Herpes Zoster (Shingles)

It is not so easy for a person with rheumatic disease to protect themselves from shingles because only live vaccines are available. There are no killed vaccines as of this moment.

Shingles is the reactivation of the chicken pox (varicella) virus and is associated with aging, since the immune system loses some strength with age. Taking immunosuppressive agents increases the risk for shingles as well. Once a person gets chicken pox and recovers from it, the virus continues to stay in the body forever. At some point in life, it might start to remultiply in the nerve presenting itself as a band-like pattern on the body surface. After a shingles infection, some patients develop a severe pain syndrome in the area where they had the rash.

The shingles vaccine can help prevent shingles from occurring, and, when shingles does occur, it can make it less likely to get the pain syndrome (which is called post-herpetic neuralgia). Also, a person should receive antiviral treatment as soon as shingles is diagnosed, which can reduce the risk of postherpetic neuralgia.

As we mature, the value of the vaccine in preventing shingles decreases. It can decrease to as low as 20% as a patient ages, but its ability to prevent postherpetic neuralgia stays the same.

The shingles vaccine prevents about 65% of postherpetic neuralgia cases. Before taking this vaccine, it is essential that you consult your rheumatologist because this is a live vaccine. If you are on a biologic agent, such as Benlysta, the use of the shingles vaccine will likely be deferred.

Screening for Herpes Zoster Vaccine Eligibility

Screening for a history of chickenpox is not necessary in order to administer the vaccine to a person 50 years of age or older. Those who were born in the United States before 1980 are assumed to have been exposed to chickenpox regardless of their recollection of chickenpox.

Complications of Herpes Zoster (“Shingles”) Infection

  • Postherpetic neuralgia, which can persist for weeks or months after rash resolves
  • Ophthalmic zoster, which is the involvement of the ophthalmic division of the trigeminal nerve and the eye
  • Dissemination with generalized skin eruptions and involvement of the central nervous system, lung, liver, and pancreas

The Herpes Zoster (Shingles) Vaccine:

  • Zostavax:
    • Contains live attenuated varicella virus in an amount that is approximately 14 times greater than that in regular varicella (Chickenpox) vaccine
    • Approved for persons 50 years and older
    • Administered by an injection under the skin (subcutaneous).

For those anticipating receiving an immunosuppressive medication, the Zoster vaccine should be administered at least 14 days before initiation of immunosuppressive therapy, although some experts advise waiting a full month after zoster vaccination to begin immunosuppressive therapy.

For those who are immunocompromised and on immunosuppressive therapies such as:

  • Corticosteroids (> 20 mg/day of prednisone) lasting two or more weeks
    •  Zoster vaccination should be delayed for a least 1 month after discontinuation of such therapy
  • Methotrexate (< 0.4 mg/Kg/week), Azathioprine (< 3.0 mg/Kg/day), or 6-mercaptopurine (< 1.5 mg/Kg/day)
    • Zoster vaccination does not need to be delayed

Tetanus, Diphtheria and Acellular Pertussis

Tetanus is a disease caused by bacteria that enters the body through breaks in the skin, and the symptoms are characterized by painful muscle spasms, breathing problems and paralysis.

Diphtheria is a disease that causes a thick coating in the back of the nose or throat, making it difficult to breathe and swallow. It may also attack the heart and nerves.

Pertussis, also called “whooping cough” is highly contagious, causing prolonged, distinct coughing, and remains incompletely controlled in the U.S. There is currently a worldwide epidemic of pertussis.

Tetanus, Diphtheria and Acellular Pertussis (Tdap) Vaccine

The Tdap vaccine acts as a defense against whooping cough, tetanus and diphtheria. It is recommended that this vaccine be given once in adulthood. It is not a live virus vaccine.

Side Effects of Tdap Vaccine

Pain (67%), redness, swelling at injection site (20%); fever (1%), headache (40%), tiredness (33%), nausea, vomiting, diarrhea (1-3%), chills, body/joint aches, rash, swollen glands.

Patients are advised not to take this vaccine if they have had a life-threatening allergic reaction after a dose of any tetanus, diphtheria or pertussis-containing vaccines or if they have had a severe allergy to any part of this vaccine.

Patients should not take this vaccine if they have had a coma or multiple seizures within 7 days after a childhood dose of DTP or Dtap. Dr. Brause advises those who have epilepsy, other nervous system problems, or if they have ever had Guillain-Barre Syndrome to check with their doctors before taking this vaccine.  However, these problems are very uncommon.

Tuberculosis

Mycobacterium tuberculosis (TB) can present as active tuberculosis or can be discovered by skin or blood testing to be a latent (inactive) infection. TB is a usually respiratory infection that starts in the lungs and slowly travels into the bloodstream and throughout the whole body. Latent tuberculosis means that a person has the infection, but it is not active – the infection is not visible and the infection is not felt by the infected person. The latent infection is particularly concerning to physicians because the patient is often unaware that they are infected.

Those with rheumatic diseases are more susceptible to TB or latent TB reactivations due to biologic agents, DMARDS and steroids that can diminish the immune system’s potency. Screening evaluations for latent or active TB infections should be conducted prior to starting immunosuppressive therapies to reduce the risk of reactivating latent TB.. Other risks include: history of prior exposure to TB, drug addiction, HIV infection, birth or extended living in a region of high TB prevalence, and working or living in high-risk settings for TB such as jails, homeless shelters and drug rehabilitation centers.

Patients can be tested for latent TB, through a tuberculin skin test or blood test (interferon release blood assays such as Quantiferon Gold). If positive, treatment should be administered prior to any rheumatic disease-related immunosuppressant therapy that can interfere with immune function. Initiating anti-TB therapy one month prior to starting immunosuppressant therapy can substantially decrease the risk of latent TB reactivation. The treatment regimens for both types of TB include the following:

  • Latent TB Infection - Treatment: INH 300mg daily + B6 50mg QD X 9 months or INH + Rifapentine weekly + B6 daily X 12 weeks
    • Can start Biologic agent after 1 month
  • Active TB Infection - Treatment: 2-5 drugs daily for 9-12 months
    • Can start Biologic agent after 1 month

Prosthetic Joint Infection Prevention

Before a hip, knee, or other prosthetic joint surgery, Dr. Brause emphasized that a patient with a chronic dermatitis condition should see a dermatologist to make sure any skin conditions (such as psoriasis or eczema) are under optimal control. Any visible lesions or breaks in the skin can predispose a patient to infection. All dental needs, such as cleanings or dental procedures, should be addressed prior to the operation as well.

The most common types of infections which can be spread to the prosthetic joint through the bloodstream include: skin problems, teeth/gum problems, and urinary tract infections (UTIs). Any bladder procedures also need to be completed before surgery. If these procedures are not taken care of prior to surgery, an infection could travel through the bloodstream and infect the prosthesis.

During surgery, the care team will work to reduce the infection rate as best they can through the use of prophylactic antibiotics and laminar air-flow. Prophylactic administration refers to the act of administering antibiotics prior to surgery in order to prevent infection. Laminar air-flow is a system that filters and cleans the air in the operating room.

After surgery, it is essential to visit the dermatologist if you have a chronic dermatitis condition in order to maintain intact skin and keep chronic dermatitis under control. It is also essential to keep teeth/gums healthy and take care of any UTIs promptly.

It is recommended that prophylactic antibiotic therapy be taken prior to certain dental and urological procedures for 2 years post-implantation. In patients with inflammatory arthritis, those who are  receiving immunosuppression treatment, patients with insulin-dependent diabetes, those with  a history of prior prosthetic joint infection, hemophilia or who suffer from malnutrition, it is recommended that prophylactic antibiotic therapy be given prior to certain dental and urological procedures for life. If any of the above conditions apply to you, you should discuss this with your dentist or your urologist.

It should be noted that for high-risk procedures like prosthetic joint surgery, it has not been proven that antibiotics must be taken, but it’s a common belief. If you are very allergic to antibiotics, then you should talk to your doctor. If you can tolerate small, one-time doses of antibiotics, it may be something to consider.

Conclusion

Dr. Brause concluded his talk by emphasizing the importance of protecting yourself from infectious diseases through vaccinations. Several vaccines can be beneficial and effective for people with rheumatic diseases such as lupus. Before making any decisions, however, it is essential to talk to your rheumatologist to ensure that you receive your vaccinations safely and appropriately.

Summary completed by Melissa Flores, Masters of Social Work intern and SLE Workshop Coordinator

Edited by Nancy Novick.

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