In this podcast, Kevin Winthrop, MD, MPH, talks about how vaccinations affect individuals with immunocompromised immune systems, the challenges associated with vaccination, and what rheumatologists should know about vaccines in 2020.

Additional Resource:

Curtis J, Bridges SL, Cofield SS, et al. Results from a randomized controlled trial of the safety of the live varicella vaccine in TNF-treated patients. Paper presented at: The 2019 American College of Rheumatology (ACR)/Association of Rheumatology Professionals (ARP) Annual Meeting; November 8-13, 2019; Atlanta, GA. https://acrabstracts.org/abstract/results-from-a-randomized-controlled-trial-of-the-safety-of-the-live-varicella-vaccine-in-tnf-treated-patients.

Kevin Winthrop, MD, MPH, is professor of infectious diseases and public health at the Oregon Health & Science University in Portland, Oregon.

TRANSCRIPT:

Amanda Balbi: Hello, everyone, and welcome to another installment of Podcast360, your go‑to resource for medical news and clinical updates. I'm your moderator, Amanda Balbi, with Consultant360 Specialty Network.

In general, health care providers should know all about the power of vaccines and their effects among individuals with compromised immune systems. However, there has been minimal evaluation of the safety of live virus vaccines among patients receiving biologic therapies who may be immunocompromised.

To shed light on vaccination among patients who are immunocompromised, like those with rheumatoid arthritis or other rheumatic diseases, today I'm speaking with Dr Kevin Winthrop, who is a professor of infectious diseases and public health at the Oregon Health and Science University in Portland, Oregon.

Thank you for joining me today, Dr Winthrop. To start, can you give us an overview about why vaccinations are important for patients with rheumatic diseases?

Kevin Winthrop: Sure, it's a great question. Vaccinations are important for everyone—for children and adults—and particularly people at higher risk than others in terms of the more likely to have certain vaccine preventable infections or having a higher risk of morbidity and mortality associated with those infections.

That really leads us to high-risk groups like immunosuppressed individuals. Most patients in rheumatology, not all but most of them, are immunosuppressed either by their disease or by the disease-modifying drugs that are being used to treat their disease. Risk varies according to infection. It varies according to immunosuppressive agents being used.

Suffice it to say, most of these patients are in a high-risk group. It is a group that we like to talk about and really target as one where we can make a big impact by preventing infections through vaccination.

Amanda Balbi: Absolutely. What are some challenges associated with vaccination and rheumatic disease management?

Kevin Winthrop: One of the biggest challenges to vaccination isn't unique to the setting of rheumatology. It's really a global challenge, which is to deliver vaccines to the people who need them most or at least get them to take them or accept them. Certainly, high-risk groups overall tend to have higher acceptance rates or vaccination rates than the general population, but they're still low.

For example, with influenza—Most years, people who are at high risk for influenza in complications of influenza, only about 40% of those people end up getting vaccinated annually. Similarly, for pneumococcal vaccination, the percentage of people adequately vaccinated is low among high‑risk populations; it is higher than influenza, it’s maybe 60%, 70%, something like that. It's not where it should be. We should be getting 80%, 90%+ of those types of people vaccinated. That's a big challenge.

Part of that is a systematic issue. Questions of who's doing the vaccination. Is it the primary care doctor? Is it the rheumatologist? Is it the pharmacist?

Issues of communication between the specialists and between patients and those as physicians, or providers like the pharmacists. That can be confusing or a barrier in some cases. I'm a big fan of the rheumatologist driving the vaccinations for their patients for a couple reasons. (A) They're really in tune with it. (B) They know their immunosuppressive drugs when they're using them, which ones might present a contraindication to the vaccine, which ones might affect the immunogenicity or efficacy of the vaccine.

For them, the timing of the vaccination, they're in the driver's seat. They're the most likely to best understand that. I favor that model where the rheumatologist really takes control the vaccination schedule or making sure someone gets vaccinated.

They can either do it themselves or, of course, send a note to the primary care doctor saying, "Hey, it'd be good to vaccinate this person now against XYZ or in 2 months against XYZ."

That's some of the barriers. Sometimes, it's cost. Some of the vaccines aren't fully reimbursed, or patients are slightly out of the age group where the vaccine is paid for, for example. Sometimes, that can be a barrier.

Lastly, I would just say there's often fears of [adverse] effects, which are largely unwarranted. There are certainly some [adverse] effects, but almost all of them are mild and rare. Severe [adverse] effects are very, very rare and shouldn't be a barrier to vaccination.

Perceptions of efficacy. Also lastly, sometimes, people think the vaccines don't work very well. Sometimes, they're right. Vaccines, some work better than others. To be honest, in a lot of cases or most cases, we don't have good efficacy data. We have immunogenicity data for most vaccines in terms of how well they build immune response to a certain antigen, and yet, all we really care about is the efficacy, and we don't often have that. If we had better studies showing, it might be easier to convince patients to receive the vaccine.

Amanda Balbi: Absolutely. Do you think there are ever any instances where a rheumatologist should not follow a vaccination schedule?

Kevin Winthrop: For adults, it's not really a schedule per se. Really, that's a pediatric concern where kids are supposed to get certain vaccines at certain ages. For adults, there is some of that. When you hit 50 [years], you're eligible for shingles vaccine, for example.

In general, most of the adult vaccinations aren't really on a schedule per se. I think what's really important for the rheumatologist is to understand how their DMARDs are affecting the vaccine.

For example, I saw lady on rituximab last week, and she was 5 days before her next infusion. It's been just about 6 months. I gave her a vaccine. I gave her a pneumococcal vaccine that day and an influenza vaccine. I had the rheumatologist push out her rituximab another 2 weeks so that she had adequate time to build immunity to those vaccines.

That's important. Had she gotten those vaccines a month from now after her rituximab administration, the vaccines probably would have done nothing. Paying attention to those timing issues is really important, particularly rituximab and sometimes also with other drugs like methotrexate. There are other specific examples out there.

The bottom line is ... That's why we need research around these drugs and how they affect drug seeing response. Number one. We have some of that, but we could have more. Number two. That's why, again, rheumatologists tend to be up on that information and are probably best suited to figure out when the best time is to vaccinate their patients.

Amanda Balbi: Great: What would you say rheumatologists need to know about vaccinations for people with rheumatic diseases, especially in 2020? Are there any take‑home messages?

Kevin Winthrop: Like I said before, I think rheumatologists really need to know which vaccines are indicated for their patients, when the optimal time to give them is, and how to handle the DMARDs around the time of vaccination if needed.

There are specific things there. Rituximab annihilates humoral vaccine responses. The farther away you are from rituximab, the better your vaccinations. There's a few studies suggesting that methotrexate being held for 2 weeks assists in influenza vaccine response. That's a strategy that could be considered.

There are lots of studies underway to evaluate that idea with other vaccines. There's a whole moving target in the whole area of shingles prevention, which is of high interest to rheumatologists, given the high risk of shingles than many of their patients have. There's a new vaccine out. There's multiple studies being started to evaluate the new vaccine.

I think in 2020, there will be some data toward the end of the year and, in 2021, a lot more data that will hopefully guide the timing of that new vaccine. When's the best time to do it? How effective is it? Are there any safety concerns, etc.? We're just lacking data.

In the next year or 2, that can be exciting. Shingle prevention is really a moving target at this point. That's something to look forward to as a rheumatologist. We need more research, and we don't have a lot of studies involving the response of efficacy of vaccines in general, outside of influenza and pneumococcal vaccines, and a little bit of shingles vaccine data.

There's the opportunity to study a wide range of vaccinations. A lot of these other vaccines or travel vaccines are niche vaccines and are not widely applicable, like pneumococcal or influenza vaccine. We do need more studies with some of the other vaccines.

As all these new DMARDs and new mechanisms of actions come out, we need to continue to invest in studying how they affect our regular vaccines, like influenza, pneumococcal, etc. We'll eventually also have new vaccines out, like the shingles vaccine I was speaking about. We'll have to, again, invest in understanding.

I guess that's my last message. One, for needed research so we can educate doctors and patients about the best way to do these things and to convince them to do them. Without the research, it's hard to do that. That would be my last pitch.

Amanda Balbi: Thank you again so much for speaking with me today and sharing your insight.

Kevin Winthrop: Thank you very much for listening today. I hope this has been helpful. This is Kevin Winthrop from Portland, Oregon. It's sunny. It's beautiful. We are thinking about the vaccinations all the time, and I hope you will too. Cheers.