There are a number of issues that need to be considered when choosing the timing and efficacy of vaccinations for immunosuppressed patients with rheumatic disease since the risk of infection in this population is twice that faced by patients without rheumatic disease.

     Which vaccinations appear to be safe? According to Camille N. Kotton, M.D., of Massachusetts General Hospital, speaking at the most recent American College of Rheumatology (ACR) conference, "Influenza and pneumococcal vaccines appear safe and immunogenic." She noted that both vaccinations are recommended by the Centers for Disease Control and Prevention (CDC) and the ACR. The exception is the live nasal influenza vaccine. Dr. Kotton cautioned that, in fact, all live viral vaccines should be avoided when dealing with immunosuppression.

     With regard to varicella (chickenpox), Dr. Kotton noted that the majority of American adults are already protected--more than 95 percent by age 29, even most of those who deny ever having had the disease.

     As for the herpes zoster (shingles) vaccine, Dr. Kotton cited the ACR Guidelines Taskforce Panel recommendation that "patients with rheumatoid arthritis receiving leflunomide, methotrexate, or sulfasalazine can be immunized with inactive viral vaccines (e.g., influenza and pneumococcal) in accordance with CDC recommendations. They recommend avoidance of live viral vaccine preparations (e.g., Zostavax) with all biologic agents, but provide no directives on whether live vaccines are safe with MTX or corticosteroid use."

     What care should be taken in vaccinating family members of the immunosuppressed? Dr. Kotton said to avoid the live influenza and oral polio and smallpox vaccines. As for varicella vaccinations for family members, Dr. Kotton said that recommendations from the American Academy of Pediatrics indicate that the presence of an immunodeficient family member does not contraindicate vaccine use in other family members. She noted that vaccinations for mumps, measles, rubella, and yellow fever are also acceptable for family members.

--Source: "Timing, efficacy must be considered when vaccinating the immunosuppressed," Daily News, ACR/ARHP Scientific Meeting, October 24-29, 2008