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Vaccination Recommendations for Rheumatic Patients - An Overview

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Patients suffering from rheumatic diseases have a relatively weakened immune system owing to ongoing immunosuppressive therapy. Read on to learn more.

Written by

Dr. Janvi Soni

Medically reviewed by

Dr. Anshul Varshney

Published At February 13, 2024
Reviewed AtFebruary 13, 2024

What Are Rheumatic Diseases?

Rheumatic disease is a broad term that groups various autoimmune inflammatory disorders that severely affect the musculoskeletal system. The bones, joints, and supporting structures, including the tendon, ligament, and cartilage, are directly impacted by inflammatory chemicals like chemokines. These chemicals are produced due to the body's highly active immune system that attempts to target one's healthy living cells and tissue structure. This exaggerated immune system response is compensated by administering immunosuppressants to patients with rheumatic disease.

Some common rheumatic diseases include:

  • Rheumatoid Arthritis: This is a chronic, progressive disorder characterized by damage to the inner lining of the joint capsule.

  • Osteoarthritis: This is an example of degenerative rheumatic disease that involves damage to the joint structure and cartilage due to mechanical wear and tear of the bones involved.

  • Gout: This is a chronic condition that involves hypersecretion of uric acid, which accumulates in the joint spaces of urate crystals. Extreme painful episodes called gout flares are experienced.

  • Ankylosing Spondylitis: This is a common autoimmune disease, mainly leading to arthritic changes in the spine. It impacts spine mobility to a great extent owing to the fusion of the vertebrae bones comprising the spinal column.

  • Systemic Lupus Erythematosus (SLE): This is also among the most common autoimmunity-mediated diseases that involve inflammation of various joints, organs, and organ systems. It is a female-dominated disease with a male-to-female ratio of 1:9.

What Causes Rheumatic Diseases?

Rheumatic diseases are autoimmune in origin. The exact reason for one’s immune system to behave in such an abnormal fashion is not yet certain. Various factors are said to contribute to the development of autoimmune inflammatory diseases.

1. Family History Or Genetic Make-up

A person having a family history of rheumatic patients is more likely to carry the autoimmunity gene that may potentiate the same disease in the carrier.

2. Environmental Factors

Various environmental factors are said to play a role in triggering the immune system to generate an abnormal response. Habits like smoking are also marked to influence one’s autoimmunity.

3. Lifestyle choices

A sedentary lifestyle impacts one’s physical and mental health to a great extent and may predispose one to rheumatic diseases.

4. Extreme Wear and Tear of the Joint

Repeated use of the joint leads to over-usage, which contributes to the mechanical wear and tear of the joint structure. The damaged joint may pose a challenge in accomplishing simple movements, thus hindering one’s quality of life. Athletes and sportspersons are more prone to such type of damage compared to people who do not include regular fitness activity in their routine.

5. Immunological Factors

The functioning of the immune system plays a significant role in the manifestations of rheumatic diseases. Women tend to be more predisposed to autoimmune disorders compared to men. This gender bias is owed to the highly active immune system of women due to factors like pregnancy, childbirth, and hormonal imbalances. The immune system response is kept in check by initiating immunosuppressive therapy in patients. However, this therapy also comes bearing with it the potential risk of infections and illnesses. To prevent one from getting a serious sickness, various immunization methods that need timely administration are recommended. The rest of the article discusses the vaccines every rheumatic patient must be familiar with.

What Are the Symptoms Of Rheumatic Diseases?

Every rheumatic disease has a specific set of symptoms associated with it. However, some generalized symptoms observed in all types include:

  1. Inflamed joints that are warm and tender to touch.

  2. Pain in joints that worsens with disease progression.

  3. Stiffness of joints is experienced, especially during the first hour of waking up in the morning.

  4. Limited range of motion of the joint; reduced flexibility.

  5. Tiredness and fatigue.

What Are the Various Vaccines Administered to Rheumatic Patients?

There is no accurate data available that specifies the type of vaccination to be administered to rheumatic patients on immunosuppressants. However, the weakened immune system may be provided extra support to fight infections that are otherwise easily preventable by immunization. Two main categories of vaccines are discussed below:

  1. Non-live Vaccines: These are the vaccines that consist of a component or protein of the dead bacteria or virus. The germ injected belongs to an unactivated version and is thus less likely to improve immunization against the disease. Examples of non-live vaccines include Hepatitis A, Polio, Influenza, and Rabies.

  2. Live Vaccines: These are vaccines that use weakened forms of live viruses, or bacteria. Examples include measles, mumps, and chicken pox.

It is important to note that live vaccines are to be administered at least two weeks before initiating immunosuppressant therapy in rheumatic patients. These vaccines are generally contraindicated in rheumatic patients on immunosuppressant therapy.

The non-live vaccines administered are discussed below:

  • Pneumococcal Vaccine: Ideally, the vaccination needs to be performed before immunosuppressant therapy. However, if that is not possible, one can get vaccinated when immunosuppression is low.

  • Hepatitis A Virus (HAV) Vaccine: For patients receiving immunosuppressive therapy a two-dose series of this vaccine is mandatory.

  • Hepatitis B Virus Vaccine: All patients <60 years of age or >60 years of age accompanied with liver disease or other inflammatory disorders must be vaccinated with a hepatitis B virus vaccine. The dosage of the vaccine is not determined specifically for rheumatic patients.

  • Human Papillomavirus (HPV) Vaccine: Rheumatic patients are more likely to develop HPV infections, increasing their risk for developing cervical cancer. Hence, it is recommended for rheumatic patients up to age 45 to get vaccinated with the HPV vaccine.

  • COVID-19 Vaccine: This vaccine is urged to all rheumatic patients irrespective of active immunosuppressant therapy.

  • Other non-live vaccines like tetanus, diphtheria, and meningococcus should be administered the same way as the normal adult population.

The live vaccines that must be administered to rheumatic patients are:

  • Measles, Mumps, Rubella Vaccine: Two doses of the MMR vaccine must be mandated in all rheumatic patients who have not been previously vaccinated or are potentially exposed to MMR virus infection due to work or travel. Care should be taken to not vaccinate the patients with ongoing immunosuppression.

  • Varicella Vaccination: Two doses that are four to eight weeks apart must be administered to rheumatic patients who have not previously been exposed to the varicella virus. The vaccination should be completed at least four weeks before initiating immunosuppressive therapy. For patients who are already on immunosuppressants, the non-live zoster vaccine is the preferred alternative.

  • Yellow Fever Vaccine: This vaccine must be administered to rheumatic patients who are living in yellow fever endemic regions or are traveling to one of these regions. The vaccine is strictly contraindicated in patients with on-going immunosuppressant therapy, similar to other live vaccines.

  • Other live vaccines include the rotavirus, typhoid, influenza, and the Japanese encephalitis virus.

Conclusion

Patients suffering from autoimmune inflammatory rheumatic diseases (AIIRD) are already predisposed to various types of infections due to an abnormal immune system complemented with a suppressed immune response. Therefore, being vaccinated against otherwise preventable infections is necessary to reduce the morbidity of such patients. It is the health care provider or the rheumatologist who is responsible for guiding the patients on these essential matters. A risk of life-threatening infection can be easily avoided if the right steps are taken at the right time.

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Dr. Anshul Varshney
Dr. Anshul Varshney

Internal Medicine

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