1. B Y N E H A L H A M D Y
EULAR recommendations for
vaccination in adult patients with
autoimmune inflammatory
rheumatic diseases

2. • The vaccination status should be assessed in the
initial work-up of patients with AIIRD (no grade of
evidence possible; strength of recommendation D;
Delphi vote 9.50)

4. • Vaccination in patients with AIIRD should ideally be
administered during stable disease (no grade of
evidence possible; strength of recommendation D;
Delphi vote 8.88)

5.  Live attenuated vaccines should be avoided whenever
possible in immunosuppressed patients with AIIRD
(grade of evidence IV; strength of recommendation D;
Delphi vote 9.25)

6. Live attenuated vaccine
 Viral:
• measles vaccine
• mumps vaccine
• rubella vaccine
• Live attenuated influenza vaccine( 2009 H1N1 flu)
• chicken pox vaccine
• Oral polio vaccine
• rotavirus vaccine
• yellow fever vaccine
• Rabies vaccines
• herpes zoster vaccine
 Bacterial:
• BCG vaccine
• typhoid vaccine

7.  Vaccination in patients with AIIRD can be administered during the use
of disease-modifying anti rheumatic drugs and tumor necrosis factor α
blocking agents but should ideally be administered before
starting B cell depleting biological therapy (grade of evidence
IIa; strength of recommendation B; Delphi vote 9.13)

8.  The use of live vaccines is contra-indicated unless
immunosuppressive are stopped at least 3 months
beforehand.
 Salazopyrine shouldn’t be given in combination with
varcillea vaccine for fear of Reye syndrome.

9. DMARD & ANTI TNF
 Azathioprine decreased the effacy influenza vaccination in
patients with SLE .
 The combination of TNFα blocking agents and MTX
reduced the response to pneumococcal vaccination in
patients with RA.

10. Rituximab
 Humoral responses following influenza
&pneumococcal vaccination 1–3 months
after treatment are severely decreased.
when patients are on rituximab already,
vaccines are given at least 6 months after
the start but 4weeks before the next course.

11. Patients on steroids
 no contraindication to give killed vaccine.
 Live vaccines must not be given to patients taking moderate or high
doses of steroids for longer than 2 weeks.
There are no contra-indications to using live vaccines if:
• Steroid is for less than 2 weeks.
• Treatment is alternate day with short acting steroid.
• By topical application.
• By intra articular or soft tissue injection.
• Long term low dose steroids (10mg per day or less).
Moderate or high dose steroid must be stopped 3 months before live
vaccines can be administered.

12.  Inactivated influenza vaccination should be strongly
considered for patients with AIIRD (grade of
evidence Ib–III; strength of recommendation B–C;
Delphi vote 9.00)

13.  Influenza vaccination has been shown to reduce
mortality from pneumonia in patients with RA, SLE,
and SSc (Stojanovich L.,2008)
Trade name of seasonal influenza vaccine
 Vaxigrip
 Fluarix
 Influvac

14.  23-valent polysaccharide pneumococcal vaccination
(23-PPV)should be strongly considered for patients
with AIIRD (grade of evidence Ib–III; strength of
recommendation B–C; Delphi vote 8.19)

15. Trade name of pneumococcal vaccine
• Pneumovax 23
• Prevenar 13
• Pneuimmune 23

16.  Patients with AIIRD should receive tetanus toxoid
vaccination in accordance to recommendations for
the general population.
 In case of major and/or contaminated wounds in
patients who received rituximab within the last 24
weeks, passive immunization with tetanus
immunoglobulins should be administered (grade of
evidence II;strength of recommendation B–D;
Delphi vote 9.19).

17.  In patients with RA and SLE, efficacy for tetanus
toxoid vaccination has been demonstrated to be
comparable with healthy controls.

18.  Herpes zoster vaccination may be considered in
patients with AIIRD (grade of evidence III–IV;
strength of recommendation C–D;Delphi vote 8.00)

19.  Based on increased risk of herpes zoster in patients
with rheumatological disorder.
 Herpes zoster vaccine has been shown to reduce
herpes zoste rand post-herpetic neuralgia in patients
over 60 years.
 However no studies have been performed in
patients with AIIRD.

20.  Human papilloma virus vaccination should be
considered in selected patients with AIIRD (grade of
evidence III; strength of recommendation C–D;
Delphi vote 8.44)

21.  SLE patients have increased risk to develop cancer
cervix 2ndry to HPV infection compared to healthy
population.

22.  In hyposplenic/asplenic patients with AIIRD infl
uenza,pneumococcal, Haemophilus influenzae b and
meningococcal C vaccinations are recommended
(grade of evidence IV; strength of recommendation
D; Delphi vote 9.50)

23.  asplenic patients are at risk of contracting a so called
‘overwhelming post-splenectomy infection (OPSI)’.
OPSIis caused by encapsulated bacteria (eg,
Streptococcus pneumoniae H influenzae b, Neisseria
meningitidis ) and the mortality of OPSI isup to
70%.

24.  Hepatitis A and/or B vaccination is only
recommended inpatients with AIIRD at risk (grade
of evidence II–III; strength of recommendation B–
D; Delphi vote 9.13)

25.  Vaccination forhepatitis A and/or B is only
recommended when the risk ofcontracting these
infections is increased
 (travel to or residence in endemic countries for
hepatitis A and/or B);
 increased riskof exposure to hepatitis A and/or B
(eg,medical profession, infected family member)

26.  Patients with AIIRD who plan to travel are
recommended to receive their vaccinations except
for live attenuated vaccines which should be avoided
whenever possible in immunosuppressed patients
with AIIRD (no grade of evidence; strength of
recommendation D; Delphi vote 9.25)

27.  BCG vaccination is not recommended in patients
with AIIRD(grade of evidence III; strength of
recommendation C–D;Delphi vote 9.38
 BCG vaccine considered to be given in juvenile
arthritis 4weeks before immunosuppressives.