Background/Purpose:

Patients with rheumatologic disorders often require immunosuppression (e.g. DMARDs, biologics, or high doses of prednisone). These patients are at increased risk for infections. While live vaccines are contraindicated in the immunosuppressed, 2018 CDC guidelines support inactivated vaccine administration [1]. Despite recommendations for immunization [2], there is lack of evidence on whether vaccination rates are optimal. The purpose of this study was to investigate the rates of influenza, pneumococcal, and tetanus/diphtheria/pertussis (Tdap) vaccination in immunosuppressed individuals with rheumatologic disorders seen from 2012-2017 at a large academic rheumatology clinic.

Methods:

Patients seen at a large urban academic medical center’s rheumatology clinic between 2012-2017 were included if they had a diagnosis of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), or vasculitis in addition to any of the following: prednisone ≥20mg/day, a DMARD (except hydroxychloroquine), and/or a biologic agent. Deceased patients were excluded. Immunizations, medications, and comorbidities were recorded. Vaccination administration for Prevnar, Pneumovax, Influenza, or Tdap was assessed. Chi squared tests evaluated immunization patterns based on various factors including sex, comorbidities, physician experience level (< 10 years, ≥ 10 years), diagnosis, and age group (< 65 years, ≥ 65 years).

Results:

Of 2366 patients reviewed, 1239 met inclusion/exclusion criteria. Results are shown in the Table. Vaccination rates were below 50% (except for receipt of flu vaccine once during the study period). More patients aged ≥ 65 years received Prevnar/Pneumovax than those <65 years of age. Patients with SLE had higher rates of immunization versus those with RA or vasculitis. Presence of cardiopulmonary comorbidities generally increased rates. No significant difference was found in rates based on ethnicity, sex, non-cardiopulmonary comorbidities, or physician experience.

Conclusion:

Infections contribute to morbidity and mortality for immunosuppressed patients, and guidelines recommend vaccination. The above results show strikingly low vaccination rates in this vulnerable population. Other risk factors for infection, including older age and cardiopulmonary comorbidities, were associated with higher vaccination rates. Rheumatologists may not be considering vaccination during their busy clinical practice. Education and quality improvement initiatives are needed to improve vaccination rates in Rheumatology clinics.

REFERENCE

1. CDC- Immunization schedules. https://www.cdc.gov/vaccines/schedules/hcp/adult.html. May 31, 2018
2. 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;70:414e22.

Table 1. Vaccination rates in immunocompromised patients

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/low-rates-of-immunizations-in-cohort-of-immunocompromised-patients-in-an-academic-rheumatology-practice/