Ever since the H1N1 swine flu scare a few years ago, I make it a point to get a flu vaccine every autumn. When receiving a regular physical exam from my general practitioner last week, the doctor suggested that a pneumococcal polysaccharide vaccine be added to protect against bacterial pneumonia. The nurse came in after the exam to administer the vaccine. I asked if the vaccine contained any live bacteria and she confirmed that it did not (see why below). As she was getting ready to stick my arm with the needle, the nurse mentioned that it would sting. I laughed when I saw the needle and joked that I was used to getting jabbed with various size needles for methotrexate and biological RA treatments. A release form was signed which indicated the risks and possible side effects – there were no noticeable side effects afterwards. My doctor also mentioned that I was getting close to the age to receive the shingles vaccine but probably shouldn’t receive it since this vaccine contains live viruses which may actually cause a case of shingles since I am immunosuppressed from RA medications.
This experience got me thinking about vaccines for RA patients who are immunocompromised. There are a variety of reasons for having a compromised immune system and the U.S. Centers for Disease Control (CDC) classifies those who take immunosuppressing drugs as having “iatrogenic immunosuppression”.[i] Common immunosuppressing RA medications include corticosteroids, methotrexate, leflunomide (Arava), azathioprine, and any of the biological treatments such as Enbrel, Humira, Remicade, Simponi, Cimzia, Orencia, Actemra, and Rituxan.[ii] These medications help control RA symptoms by suppressing an overactive immune system. When the immune system is suppressed or compromised, the body is more susceptible to viral and bacterial infections.
One of the medical miracles of the last century has been the development of vaccines which induce the immune system to recognize and fight off various infectious diseases caused by viruses and bacteria. Ponder the virtual eradication of terrible diseases such as smallpox and polio and it is evident that impact of vaccines on civilization is stunning.
Having a compromised immune system makes RA patients more susceptible to infectious diseases and it is important to follow recommendations for vaccinations. The National Rheumatoid Arthritis Society (NRAS) in the United Kingdom lists recommended vaccines for RA patients.[iii] They include the following common vaccines:
- Pneumococcal polysaccharide which protects against the bacteria Streptococcus pneumoniae.[iv] There are other bacterial and viral causes of pneumonia which are not impacted by this vaccine.
- Influenza or “flu shot”. The vaccine if typically updated every year to cover the most common viral strains. This does not include nasal mists for flu as they contain live viruses.
- Tetanus or lockjaw (commonly combined with diphtheria and pertussis called DPT)
- Pertussis or whooping cough
- Hepatitis A & B
- Haemophilus influenza type b (Hib)
- Meningococcal (bacterial meningitis)
- Polio (injection only as the oral version contains live viruses)
- Human Papilloma virus (HPV)
- Typhoid (injection, the oral vaccine contains live bacteria)
For adults with RA, it is common to receive a pneumococcal vaccine once in a lifetime, an influenza vaccine every year, and a tetanus/DPT vaccine every ten years. Immunocompromised RA patients should speak with their doctors about which vaccinations they should and should not receive.
It is generally suggested that immunocompromised RA patients should not take vaccines which contain live viruses or bacteria. Such vaccines are often called attenuated in that the virus or bacteria are altered to make them less infectious. But these vaccines are still considered live and could induce a case of the disease in a person with a suppressed immune system. Attenuated vaccines include varicella (shingles), influenza nasal mists, measles/mumps/rubella (MMR), smallpox, yellow fever, oral polio vaccines, rotavirus, and typhoid.[v] [vi] Fortunately, many RA patients received some of these vaccines as children. There is recent research demonstrating that the live shingles vaccine may be fine for RA patients but the general consensus is not to receive this vaccine if immunocompromised.[vii]
Unfortunately, some of the live or attenuated vaccines are recommended by the Center for Disease Control when traveling overseas and immunocompromised patients must take extra caution in such circumstances.[viii] I recently had an opportunity to travel to a developing country in Africa and I decided against the trip because I could not receive some of the suggested vaccines.
Being immunocompromised as an RA patient brings various challenges in life including being cautious of various infections and cancers. Fortunately, vaccines can still be used to help fight off some serious infectious diseases.