|Vaccine type||Vaccine target||Indications|
(inactivated, killed, subunit, or recombinant)
PCV15 followed by PPSV23
|All patients who have not previously received a conjugate pneumococcal vaccine*.|
|Seasonal influenza virus||Annually for all patients¶.|
|Hepatitis A virus||At-risk patients who have not been previously vaccinated.|
|Hepatitis B virus||All patients 19 to 59 years old and at-risk patients ≥60 years old (eg, those with occupational or lifestyle risk factors) who have not been previously vaccinated; antibody titers should be checked following completion of vaccine series to ensure response.|
|Meningococcus||At-risk patients who have not been previously vaccinated, including those treated with eculizumab and those with impaired splenic function.|
|Haemophilus influenzae||At-risk patients who have not been previously vaccinated, including those with impaired splenic function.|
|Human papillomavirus (HPV)||At-risk patients 19 to 26 years oldΔ who have not been previously vaccinated.|
|Tetanus, diphtheria, pertussis (Tdap) or tetanus, diphtheria (Td)||All patients per guidelines for healthy adults (eg, single dose of Tdap followed by Td booster every 10 years).|
|Recombinant zoster vaccine (RZV; Shingrix)||Recommended prior to immunosuppression and for those on immunosuppression.|
|COVID-19 vaccines◊||All patients per guidelines for immunocompromised adults◊.|
|Live, attenuated§||Zoster vaccine, live (ZVL; Zostavax)¥|| |
Can be given prior to immunosuppression and for those on low-dose immunosuppression if RZV is not available.Contraindicated for those receiving moderately to highly immunosuppressive medications.
|Measles, mumps, rubella|| |
Patients who have not been previously vaccinated and/or lack evidence of measles immunity (measles IgG seronegative) or who may have potential for measles exposure (eg, through work or travel) when the vaccine can be given prior to immunosuppression.Contraindicated for immunosuppressed patients.
Patients who have not been previously vaccinated and/or lack evidence of varicella immunity (varicella IgG seronegative) or who may have potential for varicella exposure (eg, through work or family) when the vaccine can be given prior to immunosuppression.Contraindicated for immunosuppressed patients.
|Yellow fever|| |
Patients residing in or traveling to endemic areas prior to immunosuppression.Contraindicated for immunosuppressed patients.
As part of our routine initial evaluation of patients with AIIRD, we review each patient's vaccination history and ensure that the above vaccinations have been received when appropriate. For maximal protection, vaccinations should be given prior to the start of immunosuppressive therapy. This increases the likelihood of developing a protective immune response, particularly for rituximab, which substantially impairs the humoral immune response. Vaccinating prior to immunosuppressive therapy also allows for administration of any needed live vaccines, which are generally contraindicated once immunosuppressive therapy has started.For complete information on timing of vaccine administration and vaccine schedules, including revaccination (booster dosing), refer to the UpToDate topic on vaccinations in patients with AIIRD. For more detailed description of at-risk populations, refer to the UpToDate topics regarding each vaccine.
PCV20: 20-valent pneumococcal conjugate vaccine; PCV15: 15-valent pneumococcal conjugate vaccine; PPSV23: 23-valent pneumococcal polysaccharide vaccine; IgG: immunoglobulin G; AIIRD: autoimmune inflammatory rheumatic disease; COVID-19: coronavirus disease 2019.
* Patients with AIIRD who are planning to receive or are receiving immunosuppressive medications should receive either PCV20 alone or PCV15 followed by PPSV23 at least eight weeks later. Dosing intervals and schedule may vary if either one of these vaccines has been given previously. Please refer to the UpToDate topic on pneumococcal vaccination in adults for more detail.
¶ No formulation of the (nonlive) influenza vaccine is preferred over another, although some clinicians prefer to avoid the adjuvant-containing vaccine to avoid any potential risk of worsening autoimmune disease activity.
Δ Patients aged 27 to 45 years may also receive the vaccine based on shared clinical decision-making. Refer to UpToDate topic on HPV vaccination for further details.
◊ For vaccine selection and timing of administration, refer to the UpToDate content on COVID-19 vaccines in adults in autoimmune inflammatory rheumatic conditions.
§ Other live attenuated vaccines include the influenza nasal spray, rotavirus, oral typhoid, and some formulations of the Japanese encephalitis vaccine. For most adults, these are not indicated.¥ ZVL is no longer available in the United States.
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