Review ArticleAutoimmune disease and vaccination: impact on infectious disease prevention and a look at future applications
Introduction
Disease-modifying immunosuppressive (IS) therapies have significantly impacted disease control and quality of life for many patients with autoimmune disease (AD). Unfortunately, both ADs and IS therapy directly alter normal immunologic function, leading to increased infection risk.1, 2 Furthermore, the newer biologic agents have been associated with a higher risk of serious infections, with a pooled odds ratio of 2.0 when compared with nonbiologic disease–modifying antirheumatic drugs.3, 4 In addition, infection risk is increased between 1.79 and 3 fold for biological agents used for IS therapy when compared with nonimmunosuppressed populations.5, 6, 7, 8, 9, 10 These data demonstrate the urgent need to provide AD patients with better prophylactic measures against infection.
Infection prophylaxis in immunosuppressed patient populations using antimicrobial chemoprophylaxis, such as measures currently used in the organ transplant and human immunodeficiency virus (HIV) populations, might be considered in other subpopulations, perhaps the most heavily immunosuppressed.11, 12, 13, 14 However, limited information is available to support the efficacy of these measures in most patients with ADs, with the exception of Pneumocystis jirovecii (pneumocystis pneumonia) prophylaxis in a small, well-defined subset of patients with antineutrophil cytoplasmatic antibodies-associated vasculitis.15, 16 In contrast, most inactivated or killed adult vaccines have been studied and are recommended for routine administration in patients with various ADs. Vaccines play a key role in the prevention of both communicable diseases and of infections in susceptible populations.17 In patients with AD receiving IS therapy, vaccinations are often not offered or provided for a variety of reasons, including the fear of complications or vaccine-related illnesses, a concern for disease flare or reactivation, a perceived lack of effectiveness, or a misunderstanding of current vaccine guidelines.18 Currently, only about 20% of patients in outpatient rheumatology practices receive vaccination against both influenza and pneumococcal infections, belying the need for enhanced strategies to ensure that routine vaccinations are provided to this at-risk population.19, 20, 21 Indeed, it has been demonstrated that vaccination rates can be improved to 80% or more by using simple strategies to increase awareness of the potential benefits and safety of vaccination in this population.22 Several organizations support the administration of vaccines for vaccine-preventable diseases in patients with autoimmune disorders.17, 23 Ongoing research is now evaluating the use of vaccine models as a potential therapy for patients with AD, with initial studies demonstrating potentially beneficial effects on uncontrolled immune activation and disease activity. In this review, we will examine the efficacy, safety, and use of the current recommended vaccines for patients with autoimmune disorders, highlight key concepts for vaccination in this population, and introduce several evolving vaccination strategies that may represent the future treatment of immunologic diseases.
Section snippets
Literature search strategy
The Medline database was searched through PubMed and Ovid, using the key words, individually and in combination with specific vaccines and autoimmune disorders (using several related disease names) including but not limited to the following: “autoimmune diseases (AD),” “rheumatic disease,” “rheumatoid arthritis,” “psoriasis,” “inflammatory bowel disease,” “lupus,” “systemic lupus erythematosus (SLE),” “systemic lupus erythematosus,” “vasculitides,” “antineutrophil cytoplasmatic
Available vaccines
There are currently vaccines recommended for routine administration in patients with AD that are safe and efficacious. Inactivated, killed, subunit, or toxoid immunizations do not carry any risk of infection attributable to reactivation or dissemination of the vaccine agent and are uniformly safe for patients requiring any degree of IS therapy (only excluding those with known allergies to vaccine components). These vaccines serve to elicit the formation of active immunity by the induction of
Discussion
The potential benefit of vaccinations for both general and immunosuppressed populations is unquestionable. Patients with autoimmune disorders are at high risk for infection, and vaccines can help prevent both morbidity and mortality with a very low rate of vaccine-associated complications. Unfortunately, immunosuppressed AD patients at the highest risk for infection are infrequently offered vaccines because of a misunderstanding of risk and/or underestimation of potential benefits by patients
Acknowledgments
Conflicts of Interest: All authors have no conflicts of interest to report; no other sources of editorial support were used. The authors have read and acknowledged the journal's authorship agreement and policy on disclosure of potential conflicts of interest.
No funding support was used in the writing of this article.
The authors would like to thank the physicians who provided valuable recommendations for this article.
All authors have read, revised, and reviewed the article and have provided
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Kathleen Maksimowicz-McKinnon: Department of Medicine, Division of Rheumatology, New Center One, Suite 800, Henry Ford Hospital, 3031 W. Grand Blvd, Detroit, MI, 48202, USA [email protected].