J Rheum Dis.  2023 Jan;30(1):18-25. 10.4078/jrd.22.0012.

Physicians’ Agreement on and Implementation of the 2019 European Alliance of Associations for Rheumatology Vaccination Guideline: An International Survey

• Seo P
• Winthrop K
• Sawalha AH
• Choi S
• Hwang W
• Park HA
• Lee EB
• Park JK

• KMID: 2537491
• DOI: http://doi.org/10.4078/jrd.22.0012

Abstract

Objective
To evaluate the perspective of healthcare professionals towards the 2019 European Alliance of Associations for Rheumatology (EULAR) vaccination guideline in patients with autoimmune inflammatory rheumatic diseases (AIIRD).
Methods
Healthcare professionals who care for patients with AIIRD were invited to participate in an online survey regarding their perspective on the 2019 update of the EULAR recommendations for vaccination in adult patients with AIIRD. Level of agreement and implementation of the 6 overarching principles and 9 recommendations were rated on a 5-point Likert scale (1~5).
Results
Survey responses of 371 healthcare professionals from Asia (42.2%) and North America (41.6%), Europe (13.8%), and other countries were analyzed. Only 16.3% of participants rated their familiarity with the 2019 EULAR guideline as 5/5 (“very well”). There was a high agreement (≥4/5 rating) with the overarching principles, except for the principles applying to liveattenuated vaccines. There was a high level of agreement with the recommendations regarding influenza and pneumococcal vaccinations; implementation of these recommendations was also high. Participants also reported a high level of agreement with the remaining recommendations but did not routinely implement these recommendations.
Conclusion
The 2019 update of EULAR recommendations for the vaccination of adult patients with AIIRD is generally thought to be important by healthcare professionals, although implementation of adequate vaccination is often lacking. Better education of healthcare providers may be important to optimize the vaccination coverage for patients with AIIRD.

Keyword

Vaccination; Surveys and questionnaires; Guideline; Autoimmune diseases

Figure

• 

  Fig. 1 Familiarity with the principles and recommendations of 2019 EULAR guideline. Familiarity was rated on 1~5 scale (1=not at all, 5=very well). EULAR: European Alliance of Associations for Rheumatology.

• 

  Fig. 2 Immunosuppressive dosing limit for live-attenuated vaccines. Safe dose of prednisolone (A) methotrexate (B), and azathioprine (C) for live-attenuated vaccines (*the dose under which administration of the live-attenuated vaccines were considered safe per Centers for Disease Control and Prevention recommendations). (D) Safety of conventional DMARDs for live-attenuated vaccines: 1=completely safe; 5=strongly contraindicated. DMARDs: disease modifying antirheumatic drugs, MTX: methotrexate, SSZ: sulfasalazine, HCQ: hydroxychloroquine.

Reference

1. Au K, Reed G, Curtis JR, Kremer JM, Greenberg JD, Strand V, et al. 2011; High disease activity is associated with an increased risk of infection in patients with rheumatoid arthritis. Ann Rheum Dis. 70:785–91. DOI: 10.1136/ard.2010.128637. PMID: 21288960.

2. Doran MF, Crowson CS, Pond GR, O'Fallon WM, Gabriel SE. 2002; Frequency of infection in patients with rheumatoid arthritis compared with controls: a population-based study. Arthritis Rheum. 46:2287–93. DOI: 10.1002/art.10524. PMID: 12355475.

3. Danza A, Ruiz-Irastorza G. 2013; Infection risk in systemic lupus erythematosus patients: susceptibility factors and preventive strategies. Lupus. 22:1286–94. DOI: 10.1177/0961203313493032. PMID: 24098001.

4. van Assen S, Agmon-Levin N, Elkayam O, Cervera R, Doran MF, Dougados M, et al. 2011; EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 70:414–22. DOI: 10.1136/ard.2010.137216. PMID: 21131643.

5. Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, et al. 2008; American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 59:762–84. DOI: 10.1002/art.23721. PMID: 18512708.

6. Furer V, Rondaan C, Heijstek MW, Agmon-Levin N, van Assen S, Bijl M, et al. 2020; 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 79:39–52. DOI: 10.1136/annrheumdis-2019-215882. PMID: 31413005.

7. Krasselt M, Ivanov JP, Baerwald C, Seifert O. 2017; Low vaccination rates among patients with rheumatoid arthritis in a German outpatient clinic. Rheumatol Int. 37:229–37. DOI: 10.1007/s00296-016-3608-y. PMID: 27878345.

8. Subesinghe S, Rutherford AI, Ibrahim F, Harris H, Galloway J. 2016; A large two-centre study in to rates of influenza and pneumococcal vaccination and infection burden in rheumatoid arthritis in the UK. BMC Musculoskelet Disord. 17:322. DOI: 10.1186/s12891-016-1187-4. PMID: 27491386. PMCID: PMC4973522.

9. Hmamouchi I, Winthrop K, Launay O, Dougados M. 2015; Low rate of influenza and pneumococcal vaccine coverage in rheumatoid arthritis: data from the international COMORA cohort. Vaccine. 33:1446–52. DOI: 10.1016/j.vaccine.2015.01.065. PMID: 25659279.

10. Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, et al. 2021; American College of Rheumatology guidance for COVID-19 vaccination in patients with rheumatic and musculoskeletal diseases: version 2. Arthritis Rheumatol. 73:e30–45. DOI: 10.1002/art.41877. PMID: 34128356. PMCID: PMC8427105.

11. Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, et al. 2021; American College of Rheumatology guidance for COVID-19 vaccination in patients with rheumatic and musculoskeletal diseases: version 1. Arthritis Rheumatol. 73:1093–107. DOI: 10.1002/art.41734. PMID: 33728796. PMCID: PMC8250724.

12. Brocq O, Acquacalda E, Berthier F, Albert C, Bolla G, Millasseau E, et al. 2016; Influenza and pneumococcal vaccine coverage in 584 patients taking biological therapy for chronic inflammatory joint: a retrospective study. Joint Bone Spine. 83:155–9. DOI: 10.1016/j.jbspin.2015.11.005. PMID: 26725745.

13. Morin MP, Quach C, Fortin E, Chédeville G. 2012; Vaccination coverage in children with juvenile idiopathic arthritis followed at a paediatric tertiary care centre. Rheumatology (Oxford). 51:2046–50. DOI: 10.1093/rheumatology/kes175. PMID: 22864995.

14. Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, et al. 2016; 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol. 68:1–26. DOI: 10.1002/art.39480. PMID: 26545940.

15. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. 2020; A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 382:727–33. DOI: 10.1056/NEJMoa2001017. PMID: 31978945. PMCID: PMC7092803.

16. Mullard A. 2020; COVID-19 vaccine guidelines. Nat Rev Drug Discov. 19:577. DOI: 10.1038/d41573-020-00142-9.

17. Park JK, Lee MA, Lee EY, Song YW, Choi Y, Winthrop KL, et al. 2017; Effect of methotrexate discontinuation on efficacy of seasonal influenza vaccination in patients with rheumatoid arthritis: a randomised clinical trial. Ann Rheum Dis. 76:1559–65. DOI: 10.1136/annrheumdis-2017-211128. PMID: 28468794.

18. Park JK, Lee YJ, Shin K, Ha YJ, Lee EY, Song YW, et al. 2018; Impact of temporary methotrexate discontinuation for 2 weeks on immunogenicity of seasonal influenza vaccination in patients with rheumatoid arthritis: a randomised clinical trial. Ann Rheum Dis. 77:898–904. DOI: 10.1136/annrheumdis-2018-213222. PMID: 29572291. PMCID: PMC5965360.

19. Park JK, Choi Y, Winthrop KL, Song YW, Lee EB. 2019; Optimal time between the last methotrexate administration and seasonal influenza vaccination in rheumatoid arthritis: post hoc analysis of a randomised clinical trial. Ann Rheum Dis. 78:1283–4. DOI: 10.1136/annrheumdis-2019-215187. PMID: 30904830.