Vaccinations

When you come into contact with infection, your body’s immune system springs into action by producing special proteins called antibodies. Antibodies help your body recognise and kill the foreign organisms (usually viruses or bacteria) causing the infection.

When your immune system comes across a certain virus or bacteria for the first time, it takes a few days to produce an antibody specifically to deal with that infection. These antibodies and the cells that create them remain in your body. This means that if you come into contact with the same organism again, your body is rapidly able to make large quantities of the antibody that deals with it so that the infection is removed quickly, often before you develop any symptoms.

Vaccination is a way of introducing your body to an organism so it can be ready if you come across it again.

What types of vaccination are there?

Most vaccines contain either part of an organism or whole organisms that have been killed or inactivated. When introduced to your body , these organisms activate your immune system so it produces antibodies without causing the disease.

For a few diseases, the vaccine is in the form of a live (attenuated) virus which is altered so that it activates your immune system but isn't normally strong enough to cause the disease, unless you your immune system is affected by disease or drug treatments. Examples of live vaccines are:

• yellow fever
• measles, mumps and rubella (MMR)
• BCG, which is used to vaccinate against tuberculosis (TB)
• chickenpox and shingles.

Studies have shown that people with most rheumatic diseases are at a higher risk of infection and that infections may be more severe, for example, in people with rheumatoid arthritis. This can be due to the condition itself or its treatment, such as disease-modifying anti-inflammatory drugs (DMARDS) or steroids.

Other non-disease factors may increase the risk of infection further, such as:

• having diabetes
• drinking too much alcohol
• old age.

Rheumatoid arthritis, lupus and vasculitis are examples of an autoimmune disease, which means your immune system attacks your body’s own tissues rather than foreign bacteria or viruses. Because of their effect on the immune system, these conditions can make you more at risk of infection.

In these conditions, drugs may be used to regulate the immune system and control the disease. But because the drugs dampen down the immune system they can also make you more prone to infection.

The medical term used to describe an increased risk of infection due to drugs or disease is immunosuppression.

Find out the most up-to-date answers to your questions on the COVID-19 vaccines and arthritis

There are a number of vaccinations routinely offered to everyone in the UK, most of which are given when you’re a child. For a full list of the current UK vaccinations schedule and the ages they’re given, see the NHS Vaccination Schedule website.

If you're over the age of 65, or if you're pregnant or have a long-term health condition, then you'll fall into a high-risk group for infections. This includes people with rheumatic diseases (autoimmune or otherwise) and people on the following drug treatments:

• abatacept
• adalimumab
• azathioprine
• certolizumab pegol
• cyclophosphamide
• etanercept
• golimumab
• infliximab
• leflunomide
• mercaptopurine
• methotrexate
• mycophenolate mofetil
• prednisolone (steroid tablets)
• rituximab
• tocilizumab.

If in doubt, it’s important to check with your rheumatologist or rheumatology nurse to see whether your treatment is immunosuppressive. Talk to your local rheumatology team or GP if you’re unsure about whether you should have a certain vaccination. The advice on who should and should not have vaccination is constantly changing so if you’re invited for vaccination you should always double check with your GP or rheumatology team.

People in high-risk groups should be vaccinated against flu and pneumococcus (bacteria that can cause a certain type of pneumonia and meningitis). Some immunosuppressed patients over the age of 70 may be suitable for the shingles vaccine, but you should check with your rheumatology team that it’s suitable for you before agreeing to the injection.

Flu and swine flu

The symptoms of flu (influenza) can be worse for anyone with a weakened immune system. If you have a long-term rheumatic disease or are taking steroids or disease-modifying anti-rheumatic drugs (DMARDs) you should have a flu vaccination. Carers of people falling into high-risk groups can also be vaccinated to reduce the risk of passing on infection.

If you're being treated with rituximab, you should try to have the flu vaccine either before an infusion or 6 months after an infusion. This is because rituximab affects the cells which produce antibodies for about 6 months after each infusion. If the flu vaccine is given within 6 months of a rituximab infusion you may not be fully protected against flu.

Each year the seasonal flu vaccine is changed to provide protection against the flu viruses most likely to cause infection that year. Your GP will advise whether the seasonal flu vaccine will provide adequate cover against swine flu or any other new flu virus that may develop in the future.

Pneumococcus

Vaccination against pneumococcus is important if you fall into a high-risk group. The vaccine is designed to protect you against conditions such as septicaemia and meningitis, though the main effect is against pneumonia.

If you’re vaccinated against pneumococcus while on methotrexate, you might not respond as well to the vaccine as someone not on that medication. However, this doesn’t mean you should stop methotrexate because there will still be some level of protection from the vaccination. If you do get a pneumococcal infection, you can be treated with antibiotics.

If you’ve had the pneumococcal vaccination and your condition needs treatment with biological therapies, your rheumatologist may check how well your body has responded to the vaccination first. This is done by checking a blood test to measure the level of anti-pneumococcal antibodies. If the antibody levels are found to be low, you may be advised to have a booster vaccination before starting biological therapies. This is because people on biological therapies seem to be more prone to infections with pneumococcus.

Shingles

Shingles is a painful skin disease caused by the chickenpox virus. From 2013, people aged between 70 and 79 will be offered the shingles vaccination. Although it’s a live vaccine and so wouldn’t normally be suitable for immunosuppressed patients, it’ll be recommended for some people depending on a number of different factors.

You should NOT receive the vaccination if you’re on:

• biological therapies
• cyclophosphamide
• more than 10 mg per day of prednisolone
• more than 0.4 mg/kg/week of methotrexate
• more than 3 mg/kg/day azathioprine
• more than 1.5 mg/kg/day mercaptopurine.

As biological therapies, cyclophosphamide and methotrexate aren’t usually prescribed by your GP, they may not appear on your records with your GP and they may not know that you take them, so it’s always worth speaking with them about your drug treatment before you have the vaccination.

You also shouldn’t have the vaccination if you:

• have other conditions causing severe immunosuppression (for example leukaemia, lymphoma, HIV/AIDS)
• have active TB
• are pregnant.

At the time of writing there’s no consistent advice on whether the vaccination is safe for people taking mycophenolate, ciclosporin and leflunomide.

There don’t appear to be any factors that mean the vaccine can’t be given if you’re taking sulfasalazine and hydroxychloroquine, which aren’t considered to be immunosuppressive DMARDs.

If you do have a shingles vaccination and find out afterwards that you shouldn’t have had it, you should seek urgent advice from your GP or rheumatology department. If you’re felt to be at very high risk your doctor may suggest you stop your arthritis treatment and start taking acyclovir, an antiviral drug which is used to treat chickenpox. This drug should also be prescribed straight away if you develop a rash after immunisation.

Most rheumatology departments recommend stopping DMARDs and biological therapies if you develop shingles or chickenpox. This is because when you’re unwell your kidneys and liver may not work as well and stop the drugs being washed out from the body. This can cause immunosuppressive drugs to build up in your system, which makes it harder for your immune system to fight off infection.

If the policy at your local rheumatology department is to stop the drugs, you can normally restart treatment as soon as you feel better. You should contact your rheumatologist for further advice on the policy in your area.

Before you have a vaccination, your doctor or nurse will check that it’s safe to give it to you. They’ll also go through the possible side-effects with you. Common side-effects for all viral vaccinations may include:

• a mild fever
• pain at the injection site (this can be treated with paracetamol).

Many people with a rheumatic condition worry that vaccinations will cause a flare-up of their symptoms. However, trials have found that this isn’t the case. For example, one study showed no link between any specific vaccine (flu, tetanus, diphtheria, tick-borne encephalitis, hepatitis, polio, pneumococcus) and the risk of a flare-up of rheumatoid arthritis.

There’s also no evidence that people with rheumatic conditions or who are on DMARDs are at higher risk of side-effects, and for most people the advantages of vaccination outweigh the risks.

The flu jab is given every year. This is because the flu virus is constantly changing and your body needs to produce new antibodies to keep you fully protected. The advice that you’re given may change depending on strains of flu that are most common during that year.

The H1N1 swine flu vaccine will form part of your yearly flu injection. If you do develop symptoms of swine flu despite vaccination, you should discuss with your GP whether you should have an antiviral drug such as oseltamivir (Tamiflu). If you fall into a high-risk group, contact your GP practice each autumn to remind them that you should have the jab.

The pneumococcal vaccination is only given once, and if you're eligible for the shingles vaccine you'll only need to have this once.

There are a few people who can’t be vaccinated. This could be because of:

• a confirmed severe allergic reaction (anaphylaxis) to a previous dose of a vaccine containing some inactivated viruses or bacteria
• a confirmed allergic reaction to another substance contained in the vaccine
• an egg allergy (which means you shouldn’t have flu or yellow fever vaccines)
• a severe latex allergy – some vaccines contain latex (however latex-free vaccines may be available)
• infection (some vaccines may be delayed until you’re over an infection).

No vaccine offers 100% protection. They can fail in two ways:

• primary failure, which is when the body doesn’t produce antibodies as well as expected in response to the vaccine.
• secondary failure, which is when the body produces the antibodies as expected but the protective antibody level in the blood falls over time.

Seasonal flu vaccination will prevent flu in 70–80% of those vaccinated and pneumococcal vaccination is effective in up to 70%. The shingles vaccination reduces the risk of shingles by around 50%. 

If symptoms of flu or pneumococcal infection develop, there are effective treatments that can be used. However, it's still a good idea to take steps to reduce your risk of picking up infections.

Live vaccines, DMARDs and biological therapies

The small dose of a live organism in live vaccines may be enough to cause symptoms of the disease in people who are immunosuppressed. For this reason, live vaccines aren’t recommended if you’re on certain DMARDs or biological therapies as these are immunosuppressive drugs.

Your doctor or rheumatologist will tell you if it’s safe for you to receive a live vaccine. Normally a live vaccine would only be given if immunosuppressive drugs are stopped at least 3 months before the vaccination.

If you’ve had treatment with leflunomide, you may need to take a drug called cholestyramine to help wash the leflunomide from your system before being given a live vaccine, as it can take many months to completely flush the drug from your body.

Sometimes live vaccines will be given before immunosuppressive drugs are started. Immunosuppressive drugs shouldn’t be started for at least 2 weeks, preferably 4 weeks, after you’ve been given a live vaccine.

Live vaccines and steroid treatment

Live vaccination must not be given if you’ve been taking moderate or high-dose steroids for more than 2 weeks. The guidelines from the British Society for Rheumatology (BSR) suggest that you can have live vaccines while on steroids if:

• you’ve been on steroid treatment for less than 2 weeks
• the steroid is only applied to the skin in the form of a cream or given via an inhaler
• the steroid has been given into or around the joint by injection
• you’re on replacement therapy (for example hydrocortisone), which is given when your adrenal glands, the small glands above your kidneys, aren’t making enough steroids – this can happen with conditions such as Addison’s disease or if you’ve been on long-term steroids
• you’re on low-dose steroids, which the BSR defines as 10 mg per day or less.

Moderate or high-dose steroids must be stopped 3 months before a live vaccine can be given.

Oral vaccines

An oral vaccine is given using an inhaler. Previously polio was a live oral vaccine but it’s now usually given by an injection of inactive vaccine. Oral vaccine is usually only used during an outbreak and shouldn’t be used in immunosuppressed patients or anyone who lives with them.

The vaccinations you'll need if you’re travelling vary depending on where you’re going and on the type of travel. You can get up-to-date advice from the NHS Choices website or you can discuss it with your GP. You should take advice in the early stages of making your travel plans, but don't let your medications put you off travelling.

The risks of getting infections when you’re abroad depend on the type of travel. You’ll be at much less risk on a business trip or holiday in a top-class tourist hotel than a long trip to the countryside in some less industrialised countries. 

Travel to countries where there's a high risk of catching yellow fever, such as central Africa, should be avoided if you’re on an immunosuppressive drug because you shouldn't have a yellow fever or any other live vaccines. 

To enter some countries you need a certificate of vaccination against yellow fever even if there’s no risk of contracting yellow fever in that country. If this is required you’ll need an exemption certificate from your GP, but you should check before you travel if this is acceptable.

There are some general, day-to-day things you can do to reduce your risk of picking up an infection, including:

• washing your hands frequently
• being careful with the food you eat and water you drink, especially when you’re abroad
• avoiding unpasteurised foods (e.g. Brie, feta and blue cheeses) if you’re on immunosuppressive drugs
• contacting your doctor or the hospital early if you get a fever (temperature).

As well as simple measures like these, there are some specific ways in which certain infections can be avoided.

How can the risk of infection be reduced if I’m taking DMARDs?

Even if you do have vaccinations, if you’re on treatment with DMARDs your blood count should be checked to make sure that your body is producing enough white blood cells. This is because a low white blood cell count will decrease your body’s ability to fight infection. If your white blood cells are low, this can normally be reversed by stopping the drug and in some cases taking other drugs to improve the production of white blood cells. Examples include folic acid if you’re on methotrexate or use of a cholestyramine washout if you’re on leflunomide. This will increase your body’s ability to fight infection.

What can be done if I’m exposed to an infection?

Immunoglobulins

You can be given immunoglobulins to stop certain types of infection developing. Immunoglobulins act like your body’s antibodies. They can be used straight away if you think you’ve been exposed to:

• tetanus (your doctor or an A&E department can advise if an injury is high risk for tetanus)
• hepatitis B (for example, treatment would be considered after stabbing yourself with a needle from someone who may be carrying hepatitis B)
• rabies (for example, if you get bitten by an animal in a country which still has rabies)
• chickenpox or shingles.

Chickenpox and shingles

Chickenpox vaccination is normally given in childhood. Because it’s a live vaccination, it’s not currently recommended for people who are immunosuppressed, but most adults will have been exposed to the virus and will be immune to it.

Immunoglobulin treatment would be considered for if you’ve never had chickenpox or if you’re on immunosuppressive drugs and have had close contact (in the same room for 15 minutes or more or face-to-face contact) with someone with chickenpox. Your doctor will check your immunity (the level of antibodies in your body) and if it's low may recommend immunoglobulin treatment or aciclovir (an antiviral drug) to stop the infection developing.

Shingles can develop if you've previously had chickenpox. The shingles vaccine is currently recommended only for some people on immunosuppressive drugs. If others within the same household as someone with shingles haven’t previously had chickenpox or been vaccinated against it, it may be worth suggesting that they also have the vaccination.

You should tell your rheumatologist whether or not you've previously had chickenpox, as this is useful to know if you're exposed to the virus.

What should I look out for if I have a vaccination?

Flu

The flu vaccine should provide enough protection, but if you do develop flu-like symptoms, especially if you had the vaccine while on rituximab, please speak to your doctor about antiviral treatment, which should be started within the first 48 hours of symptoms.

Pneumococcus

Pneumococcal vaccination will only provide protection against pneumococcal pneumonia. If you develop a high fever, breathlessness, and a cough with green spit, seek medical help immediately as it’s likely that you’ll need antibiotics to stop the infection developing.