A vaccine produces immunity against a particular disease by stimulating our immune system. Thus, it prevents or reduces the severity of future infections by a specific organism. Vaccines are of various types. They usually contain the microorganism (bacterium or virus – killed or attenuated) or its toxic products. Our body recognizes the vaccine as a foreign agent and kills or destroys it. During infection by the same microorganism, memory cells come into play and destroy the organism
Patients with autoimmune diseases are at increased risk of developing infections. For example, the risk of infection in patients with rheumatoid arthritis is almost double compared to the normal population. Patients with systemic lupus erythematosus, too, have a significantly higher risk of infection. Infection is a significant cause of mortality in these cases. Immunomodulatory or immunosuppressive treatment of these diseases makes patients more susceptible to infections. However, it is generally accepted that low doses of drugs used in rheumatology practice are not severely immunosuppressive. Glucocorticoids (steroids), methotrexate, cyclophosphamide, leflunomide, azathioprine, anti-TNF agents (etanercept, infliximab, adalimumab, golimumab), and other biological agents (anakinra, rituximab, abatacept, tocilizumab) are the main immunomodulators used in rheumatology practice.
The quality of preventive response appears to be inferior in patients with autoimmune diseases. This phenomenon may be due to the disease itself or to immunomodulatory therapy. Efficacy of vaccinations seems to be lower in patients on anti-TNF and agents but normal in patients on methotrexate and azathioprine. Therefore, vaccination is frequently needed in these patients. A small risk of developing autoimmune disease following vaccination is postulated as infections can trigger an autoimmune response. A transient increase in joint pains has been observed after many vaccines. However, the risk of the development of rheumatoid arthritis does not increase. There is no evidence to suggest that vaccines increase disease activity or lead to a flare in these diseases.
Live vaccines should not be used in autoimmune inflammatory diseases. These include measles, mumps, rubella, yellow fever, typhoid, and BCG (for tuberculosis). Attenuated vaccines are safe but require booster doses. In some cases, it may be better to use immunoglobulins or anti-viral/anti-bacterial drugs to prevent or treat these diseases.
| Diphtheria, Tetanus | Every ten years |
| Whooping cough | One booster in adults |
| Polio, cholera | No live vaccine. Use killed vaccine |
| Measles, Mumps, Rubella | Contraindicated |
| Tuberculosis (BCG) | Contraindicated |
| Pneumococcal pneumonia | Every 5 years |
| Influenza | Every year |
| Swine flu (Nasal – attenuated) | Every year. Killed attenuated safer. |
| Herpes zoster, Hepatitis B | Safe |
| Hepatitis A | Safe |
| Japanese encephalitis | Safe |
| Typhoid | No live vaccine. Use Vi capsular polysaccharide vaccine |
| Rabies | Use inactivated vaccine after dog bite |
| CORONA* | Safe. Stop methotrexate a week before and after vaccination (consensus opinion). Most of the other drugs can be administered. Consult your rheumatologist for concurrent use of biological drugs. |
* Preliminary studies indicate that the formation of neutralizing antibodies is not optimum in patients on anti-rheumatic agents (methotrexate, rituximab).