Live, attenuated vaccines are made from live organisms that have been modified to make them inactive. These vaccines are close to a natural infection, which makes them good “encounters” of the immune systems.They include yellow fever, varicella-zoster, rotavirus, MMR, rubella, oral typhoid, and BCG for tuberculosis.
Individuals whose immune systems already have been compromised by antirheumatic medications may fail to respond, and a full-blown infection can occur. Consequently, most professional groups for physicians, along with Centers for Disease Control and Prevention (CDC), say that those who are immunocompromised should never receive a live, attenuated vaccine. Most patients in North America have access to adequate substitutes for live, attenuated vaccines (except for those against the zoster virus that causes shingles), but yellow fever could be a concern for those traveling to certain areas outside of United States. Check the website of the State Department and talk to your doctor about the risks and benefits of getting vaccinated before you plan the trip.
As of today, there is no sufficient medical evidence that quantifies the risks of such infection after vaccination. National Institute of Health and American College of Rheumatology are conducting a study while CDC remains appropriately conservative because live vaccines could potentially be dangerous in an immunocompromised host receiving biologic agents.
Experts also voice concern about the lack of data on how patients on biologic agents actually react to vaccines as opposed to general population. Nobody is certain that if an immune system repressed by both medications and rheumatic diseases requires a different schedule of vaccinations. It is not clear whether the vaccinated patients are meaningfully protected.
Studies of quality of care on the national level consistently show that patients with rheumatic disease are under-vaccinated per CDC standard.As the complexity of treatment options for rheumatoid diseases increases, the recommendations for vaccines have also become more complicated. This can lead to physicians’ lack of confidence in knowing what their patients actually need.The confidence concerns may lead doctors to decide not to vaccinate until these issues become clearer.There may be hesitancy by both your rheumatologist and your family physician to recommend you the vaccines due to a split in care. Vaccines have long been the focus and responsibility of the primary care physician. However, the drugs in the biologic era given and better understood by the rheumatologist are the ones causing the concerns.
It often falls to you to coordinate with both physicians regarding whether you need vaccinations and which ones are indicated, and then actually getting them either at your primary care physician’s office or local pharmacies. Many questions remain unanswered in the discussions about vaccinations for those prescribed biologic medications. Keep asking your doctors about the vaccines you need and when you need them. Make vaccination a topic of discussion during your next office visit.
Dr. Flora Bai is the founder of Arthritis and Rheumatism Institute at 2163 Oak Tree Road, Edison. She is a board certified rheumatologist and clinical instructor for Robert Wood Johnson Medical Center. For more information, call 908-754-4900 or visit www.centraljerseyrheumatology.com.