Dr. Pedro Carvalho

Reumatologista

Covid and non-covid vaccines in rheumatic diseases

HPA Magazine 17

Although rheumatic diseases put the patient at greater risk of infection, resulting in a greater morbidity and mortality, vaccination rates for these patients are still not as high as desired.
Therefore, the initial evaluation of the rheumatic patient must include the immunization history and updating data according to the National Vaccination Program (NVP). In addition, possible indications for vaccines outside the NVP should be evaluated.

Generally speaking, non-live vaccines can be safely administered to immunosuppressed patients. Live vaccines are not recommended in case of high dosage immunosuppressive treatment, however, after a correct individual assessment of the risk/benefit ratio, they may be considered in select cases.
This assessment takes into account the patient’s inherent risk factors, such as age, type of immunosuppression to which he is subject and also the vaccine in question, for example, the yellow fever vaccine represents a greater risk than others, such as the herpes zoster vaccine.
As for vaccines outside the NVP, the recommendations for patients with systemic inflammatory rheumatic disease are:
• Annual flu vaccine and pneumococcal vaccine
• Hepatitis B vaccine in patients not immune to this virus
• Hepatitis A vaccine if traveling to an endemic area
• Vaccine against the human papilloma virus, for young adults not previously vaccinated
• Benefit/risk assessment for the herpes zoster vaccine in patients aged 60 years and over.

Rheumatic patients are at particular risk in the current pandemic context and vaccination against COVID-19 is recommended. In cases where the SARS-CoV-2 virus infection occurred before the first dose of the vaccine, immunosuppressed patients should follow the recommended programme from the 3rd month after infection.
An additional dose is indicated when the vaccination programme against COVID-19 has been carried out during a period of severe immunosuppression, namely treatment with leflunomide, rituximab, cyclosporine, cyclophosphamide, azathioprine, mycophenolate mofetil, methotrexate and high doses of corticosteroids (>10mg/day for at least 3 months or >20mg/day for at least 2 weeks). The additional dosage should consist of an mRNA vaccine, with a minimum interval of 3 months after the last dosage of the vaccination.
These recommendations should be systematically applied in daily clinical practice, in order to reduce the impact that infections have on the lives of rheumatic patients.