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:
- certolizumab pegol
- mycophenolate mofetil
- prednisolone (steroid tablets)
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.
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 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
- 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 gold, 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.