- 1 Definition
- 2 Mechanism of action
- 3 Risk groups
- 4 Two important vaccines
- 5 COVID-19 vaccine
- 6 "Live" vaccines
- 7 "Dead / killed" vaccines / inactivated vaccines
- 8 Impaired vaccine effect?
- 9 child Vaccination
- 10 Vaccines during pregnancy
- 11 Breastfeeding and vaccines
- 12 Treatment with Immunoglobulins
- 13 Literature
Vaccines strengthen the immune system against infections. In rheumatic disease, there is often an increased risk of infections and thus a special need for vaccines.
In general, the benefit of vaccines for rheumatic diseases is clearly greater than the disadvantage and sometimes life-saving. In some cases, however, vaccines should be avoided or delayed. This is described under «live vaccines»Below and in the package leaflet of each preparation.
It is speculated that vaccines may cause worsening rheumatic disease and that additives can trigger rheumatic disease (ASIA syndrome). In practice, this is rarely suspected, and the benefit of vaccines for rheumatic disease is much greater than any risk.
In households where one or more people use immunosuppressive drugs, everyone should consider getting vaccinated with the annual flu vaccine to prevent the infection from infecting others.
Mechanism of action
Vaccines contain attenuated or dead viruses / bacteria / microbes or parts of them that are similar to pathogenic bacteria, viruses or other microbes. This causes the immune system to react and become stronger, but without an infection.
Every year approx. 900 people in Norway from the flu. At-risk people are especially residents of nursing homes and old people's homes, all over the age of 65, children and adults with diabetes 1 and 2, very severe obesity and a weakened immune system. There are different degrees of impaired immune system. Very vulnerable are people who have congenital severe immune deficiency, which is diagnosed in childhood. The same are risk factors for serious complications of the virus COVID-19. Use of immunosuppressive drugs such as prednisolone, Biological drugs, Azathioprine, methotrexate, CellCept with more can also be important, but more variable.
Two important vaccines
influenza vaccine (given annually) and pneumococcal vaccine (Vaccination against pneumonia is taken every 7-10 years) are «dead vaccines». (Exception: Influenza vaccine as a nasal spray, Fluenz Tetra, is a «live vaccine»). Both vaccines reduce the risk of life-threatening pneumonia. Vaccines are also recommended according to European recommendations (EULAR 2019; Furer V) including by:
- Age over 65 years
- A weakened immune system (Rheumatic disease treated with immunosuppressive drugs)
- Chronic lung or heart disease
- Several rheumatic diseases:
Otherwise, common vaccine recommendations should also be followed (The Norwegian Institute of Public Health): http://www.fhi.no/tema/vaksiner-og-vaksinasjon
The vaccines on the market at the beginning of 2021 consist of a small part of the COVID-19 virus (RNA or DNA). These fragments are not viable and can not cause viral disease ("dead vaccines"). Nevertheless, our immune system strengthens so that it is prepared if it later encounters real COVID-19 viruses. Theoretically, a vaccine-activated immune system can aggravate an autoimmune rheumatic disease, but it is less likely than an activation to occur in a real viral infection. The protective, beneficial effect of the vaccine is generally much greater than the risk of complications. Please read more about COVID-19 infection and the vaccine in a separate chapter.
Vaccines with weakened (but live) microbes can be problematic for people who have immunosuppressive drugs or weak immune system for other reasons.
Effect of "live" vaccines
- The vaccines should activate the immune system without causing illness, but still so that one becomes immune
Risk of "live" vaccines
- Weakened microbes can cause unwanted signs of infection by reduced immune system (immunosuppressive drugs).
- Vaccines may contain additives (adjuvants) that enhance the vaccine effect. Some people may react to these additives, which often contain aluminum salts. The extent of such reactions is discussed (ASIA syndrome) and must be weighed against the great benefit effect of vaccines.
Examples of "live" vaccines
- Vaccine against measles, mumps and rubella (MMR)
- Vaccine against chickenpox (Varicella)
- Measure antibody before vaccination
- Rotavirus vaccine
- Influenza vaccine as nasal spray (Fluenz Tetra), for children from 2 to 18 years of age
- Vaccine against herpes zoster (shingles)
- For people over 50 years
- Yellow fever vaccine
- Gulfber vaccine is powerful, so caution is especially important
- BCG vaccine (against tuberculosis)
- Oral vaccine (swallowed) against typhoid fever
- Oral polio vaccine (OPV) (not used in Norway)
Conditions where the use of «live » vaccines most often not to be used
- Most Congenital immune defects
- During pregnancy (Flu vaccine can be used)
- If Inficulum simab (Remicade, Inflectra, Remsima) or adalimumab (Humira) is used in the latter part of the pregnancy, the baby should not be alive vaccines first six months from the birth of (applicable to Rota virus vaccine, BCG is usually given later anyway). If the drug was stopped before pregnancy week 22, the usual vaccination program may be followed
- Symptomatic HIV infection
- Malignant conditions (cancer) during chemotherapy treatment (chemotherapy)
- In case of chronic inflammatory diseases (for example Arthritis (rheumatoid arthritis), connective tissue disorders, Vasculitis, Inflammatory bowel disease) indication must be considered individually
- Immunosuppressive treatment (methotrexate, cyclosporine, mycophenolate (CellCept), azathioprine (Azathioprine), infliximab (Remicade, Remsima), etanercept (Enbrel), Adalimumab (Humira), ritual simab (MabThera), Cyclophosphamide (Sendoxan) and more)
- After transplantation
- Prolonged steroid therapy (Prednisone, SoluMedrol) With high doses. For children with doses corresponding to more than prednisone 2 mg / kg.
- Prednisolone in doses above 20mg / day or slightly lower doses (10-15mg?) Over more than 2 weeks
Vaccine against herpes zoster (shingles) is increasingly used before immunosuppressive treatment is started among people over 50 years of age. One in four people will develop herpes zoster during their lifetime. The risk increases clearly from the age of 50 and with weakened immune systems, such as with the use of immunosuppressive drugs. Zostavax is the older vaccine that consists of live (attenuated) viruses. The vaccine against Herpes zoster can prevent about 50% of cases and has an effect for at least 3 years. Unlike the newer vaccine (Shingrix), the "live", old vaccine (Zostavax) should not be given in weakened immune systems because one can then get herpes zoster symptoms even from the weakened vaccine virus. In practice, patients must receive the old Zostavax vaccine before treatment start with powerful immunosuppressive drugs that JAK inhibitors og Biological drugs against rheumatic disease, but also Prednisone and other immunosuppressive drugs.
Children with rheumatic disease and immunosuppressive treatment is often discouraged MMR vaccine (against measles, mumps and rubella). They should be vaccinated as vaccinated when treatment is completed.
Latency between live vaccines and treatment
If vaccination with "live" vaccines is appropriate, it should be done 4 weeks or more before immunosuppressive therapy begins.
After stopping treatment with immunosuppressive drugs, one should wait 3 months before vaccination with «live vaccines» (exceptions: rituximab 6 months, Prednisolone 1 month)
"Dead / killed" vaccines / inactivated vaccines
These contain no living organisms and are safe also for immunocompromised people. However, some immunodeficiencies and some drugs (including MabThera / Rixathon) may reduce vaccine efficacy.
Examples of dead / killed vaccines / inactivated vaccines
Influenza vaccine (except influenza vaccine as a nasal spray (live vaccine) / Fluenz Tetra
- Recommended (Norwegian Medicines Agency in Norway) to
- All over the age of 65
- Residents at nursing and nursing homes
- Pregnant after 12. gestation
- Children and adults with chronic diseases where flu make up a serious health risk
- Healthcare staff with patient contact
Pneumococcal vaccine (against pneumonia)
- Recommended (National Institute of Public Health in Norway, 2017)
- All over the age of 65
- When using immunosuppressive drugs
- Spleen Deficiency
- Bone marrow transplantation
- Chronic lung or kidney disease
- Please see separate section above
Herpes zoser-vaccine in the form of Shingrix is a newer, non-live vaccine (Shingrix) became available on the Norwegian market in 2022. The vaccine has over 90% protection and a relatively small risk of side effects in people over 50 years of age. Two injections are required. The vaccine is then assumed to work for 10 years.
Polio vaccine (for injection / syringe)
- Hepatitis A vaccine
- 2 doses
- Hepatitis B vaccine
- 3 doses
- Ticks encephalitis (TBE) vaccine (not against Borrelia infection)
- 3 doses
- HPV vaccine (against human papillomavirus) consists of artificially produced particles that resemble parts of the surface of true HPV virus
- 3 doses
- Women who have SLE may be at increased risk of HPV infection related cervical cancer and should consider early vaccination
- Meningococcal vaccine
- 2 doses
- Japanese encephalitis
- 3 doses
Impaired vaccine effect?
Concomitant use of immunosuppressive drugs may reduce vaccine effect, but is dependent on the cause of impaired immune system.
- Usually, the vaccine works in people who are kidney transplanted, cancer patients who have not received chemotherapy for a few weeks and HIV patients with moderately reduced number of T cells
- Patients treated with moderate steroid doses (Prednisolone less than 20mg / day) also respond satisfactorily to vaccines
- More powerful immunosuppressive drugs may reduce vaccine response somewhat, but usually the vaccines still work sufficiently
- Methotrexate seems to reduce vaccine efficacy more than TNF inhibitors and tocilizumab (RoActemra)
- Rituximab (MabThera / Rixarthon) reduces vaccine efficacy if vaccination occurs less than 6 months after MabThera treatment
- Ideally, one should be vaccinated at least 3-4 weeks before starting treatment with rituximab
- After rituximab infusion, one should wait, if possible, 6 months of vaccination
- There is little knowledge about vaccine efficacy in people with innate immune defects
Vaccines during pregnancy
Some vaccines should not be given to pregnant women because the vaccines can harm the fetus. For all vaccines, risk and necessity must be assessed for each case.
"Live" vaccines (attenuated viruses or bacterial vaccines) should not be given during pregnancy
- Vaccines against rubella, mumps and measles (MMR) should not be given. Pregnancy should be avoided within three months of vaccination
"Dead" vaccines (dead virus or bacteria) are generally harmless
- Vaccines against polio, tetanus and diphtheria are dead vaccines and can be used
- Influenza vaccine is a "dead vaccine" and is recommended in the last 2/3 of pregnancy (in the second and third trimesters) if there is a risk of infection. Influenza vaccine is recommended for pregnant women as they become more easily infected (weakened immune system during pregnancy) and the flu can lead to pregnancy complications. The vaccine can also protect the baby for the first time after birth
Specific immunoglobulin can be given, but the effect is uncertain
Because pregnant women use certain immunosuppressive drugs (applies to all biological drugs) after the 22th week of pregnancy, it may be appropriate that the child does not receive live vaccines (most commonly applies vaccine against Rota virus) first 6 months after birth. Any BCG vaccine is postponed. If in doubt can Public Health or NKSR be contacted.
Breastfeeding and vaccines
Vaccines can be used by nursing mothers
Treatment with Immunoglobulins
Immunoglobulins can be given by weakened immune system after infection and preventative in some cases. There are specific immunoglobulins (Hepatitis B, Tetanus, Diphtheria and Rabies). Normal IgG is given by Hepatitis A and Measles.
Recommendations about vaccines (external links)
- Vaccination Program for Children in Norway (Norwegian Institute of Public Health in Norway)
- Varicella and Zoster vaccination (Norwegian Institute of Public Health in Norway)
- Children with rheumatic disease (EULAR)
- Adults with Rheumatic Disease (Furer V, 2019 EULAR)
- Vaccination and Pregnancy, Stray-Pedersen B, 2014 (Medical Association in Norway)
- Pneumonia (Information from LHL in Norway)