RA patients: immunization for respiratory bugs essential

[Guest guest]

Rheumawire

May 5, 2004

RA patients: immunization for respiratory bugs essential

Glasgow, UK - Rheumatologists should be aware of the importance of

immunization against respiratory diseases in patients with rheumatoid

arthritis (RA) and related conditions, UK researchers say.

RA patients are known to be more susceptible to infection, and some

disease-modifying antirheumatic drugs (DMARDs) diminish the ability to

cope with respiratory infections. A ish doctor highlighted the

issue of flu vaccination at the British Society of Rheumatology (BSR)

2004 meeting recently [1], while a group in Belfast is proposing that RA

patients on TNF inhibitors should be immunized against pneumococcal

disease [2].

Dr Connell (Centre for Rheumatic Disease, Glasgow Royal Infirmary,

Scotland) told rheumawire that, to her knowledge, influenza vaccination

was not a set policy in British rheumatology clinics, " but it should be

being recommended. "

Drs and Allister J Taggart (Musgrave Park Hospital,

Belfast, Northern Ireland) said, " We would advocate the need for

rheumatologists prescribing biologic therapy to give pneumococcal

vaccination as part of routine procedure. "

At the BSR conference, Connell reported an audit of RA patients at the

Glasgow Royal Infirmary, in which 115 outpatients were asked whether

they had been immunized against flu in the previous year. Of the

patients, 61 (53%) received the vaccine; the researchers recorded who

prompted them to have the immunization.

Of those not vaccinated, 29 (54%) said they were not aware they were

entitled to have the vaccine, 11 (20%) decided not to have it, 7 (13%)

were worried about side effects of the vaccine, and 6 (11%) did not

perceive themselves to be at risk. Notably, there was a significantly

higher vaccination rate in patients age 65 or over (46% of patients

under 65 were vaccinated compared with 69% of those over 65; p=0.017).

" This audit shows that there is low uptake of influenza vaccine among

DMARD-treated RA patients attending our unit, " Connell said. " The main

reason for this was lack of awareness. Uptake could be improved by

increased patient knowledge about the vaccine. "

She added: " Most patients in this audit were informed about the vaccine

by personal contact with a primary-care health professional.

Rheumatology services have a role to play in communicating with patients

and primary care about the need for vaccination. "

Connell told rheumawire: " We are now planning to promote flu vaccine

much more heavily in our clinic this autumn. " This will involve posters

on the walls and a recommendation to all patients starting DMARD therapy

that they should be vaccinated against flu, she said.

Separately, the American College of Rheumatology (ACR) recently warned

that while flu vaccination is to be encouraged in immunosuppressed

patients, they should avoid a new nasal-spray flu vaccine, FluMist®

(Medimmune/Wyeth), because it is a live attenuated vaccine [3].

Patients, their relatives, and healthcare workers should be encouraged

to receive the standard injectable inactivated flu vaccines, the ACR

notes.

Meanwhile, writing in Rheumatology, and Taggart say:

" Pneumococcal vaccination should be a routine procedure in the

management of patients treated with TNF- antagonists, and it should be

the responsibility of the physician prescribing the TNF- antagonist to

ensure each patient receives the vaccine. "

They recommend use of polyvalent capsular polysaccharide pneumococcal

vaccines and say others have also advised use of this type of product.

" [These] provide prophylactic cover for over 90% of pathogenic

pneumococcal strains in the UK, including most antibiotic-resistant

pneumococci. "

RA patients generally come under the umbrella of high-risk patient for

pneumococcal infections, they note, yet in a recent study of

general-practitioner prescribing habits, up to 50% of GPs did not

routinely vaccinate their patients at high risk of pneumococcal

infections. " There is clear evidence that pneumococcal vaccination is

seriously underused in the community, " and Taggart told

rheumawire.

The Belfast doctors say that although all patients on DMARD therapy are

technically at higher risk of respiratory-tract infections caused by

Streptococcus pneumoniae, " We feel that the risk of infection in

general, and especially pneumococcal, is higher in biologic-treated

patients, and therefore the need for vaccination in these patients is

even greater. " Patients could also be immunized against flu at the same

time they are given pneumococcal vaccines, they note.

" We do not currently have a policy of routine vaccination of our

[biologic-treated] patients; however, we hope to institute this soon, "

they added. " A statement issued by the British Society of Rheumatology

regarding the use of pneumococcal vaccination would raise awareness

within the UK, and similar statements by EULAR and ACR would help with

worldwide awareness. "

RA patients should receive the vaccine before starting biological

therapy, with reimmunization every 5 years, and Taggart say.

However, they caution that revaccination less than 3 years after the

first injection can produce serious reactions, so rheumatologists should

always check with the primary-care doctor before giving pneumococcal

vaccines, in case the patient has already been immunized.

They also warn that " despite vaccination, it is important to remain

vigilant to pneumococcal infections, as it has been shown that anti-TNF-

therapy impairs the immunogenicity of the pneumococcal vaccine. " In 1

study, only 12% to 56% of those on TNF- inhibitors responded to the

vaccine, compared with 55% to 95% of healthy controls.

Nainggolan

Sources

1. Connell L, Mc M, and Cappell HA. Audit of influenza vaccine

uptake by rheumatoid arthritis (RA) patients. Rheumatology 2004;

43(supplement 2):ii136.

2. SA and Taggart AJ. Pneumococcal vaccination for RA patients on

TNF-alpha antagonists. Rheumatology 2004; 43:523.

3. Matteson EL, Kavanaugh A, and Poland G. FluMist nasal spray influenza

vaccine: implications for rheumatology. American College of Rheumatology

2003. Available at:

http://www.rheumatology.org/publications/hotline/1003bflu.asp.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org