The uptake of influenza and pneumococcal vaccination among immunocompromised patients attending rheumatology outpatient clinics

Single-centre, cross-sectional study on the factors and reasons for non-vaccination among patients with rheumatoid arthritis

OBJECTIVES

We aimed to investigate the vaccination coverage and the factors associated with non-vaccination for vaccine-preventable diseases among patients with rheumatoid arthritis.

METHODS

This single-centre, cross-sectional study was conducted in a 715-bed regional tertiary-care teaching hospital in Japan from 1 September to 30 November 2020. Vaccination status and the factors and reasons for not receiving the influenza vaccine, 23-valent pneumococcal polysaccharide vaccine (PPSV23), 13-valent pneumococcal conjugate vaccine (PCV13), and varicella vaccine live (VVL) were investigated.

RESULTS

Among 991 patients, the vaccination coverage for the influenza vaccine, PPSV23, PCV13, and VVL was 62%, 46%, 14%, and 3%, respectively. The most common reasons for vaccine hesitancy were efficacy concerns for the influenza vaccine, safety concerns for the PPSV23 and PCV13, and both efficacy and safety concerns for the VVL. Younger age, no use of biologics or other hospital visits, and public assistance were factors significantly associated with non-vaccination for the influenza vaccine; younger age, short disease duration, and no visits to other hospitals for PPSV23; younger age, no hospitalisation, more experienced doctor, and no medical immunodeficiency for PCV13.

CONCLUSIONS

We found that the factors associated with non-vaccination varied by vaccine type; therefore, vaccinations should be promoted with individualised strategies.

Vaccination in the Era of Immunosuppression

Patients with autoimmune inflammatory rheumatic diseases (AIIRDs) are at increased risk for severe infections. Vaccine responses and safety profiles may differ between AIIRD patients and the general population. While patients with autoimmune inflammatory rheumatic diseases (AIIRDs) often experience diminished humoral responses and reduced vaccine efficacy, factors such as the type of immunosuppressant medications used and the specific vaccine employed contribute to these outcomes. Notably, individuals undergoing B cell depletion therapy tend to have poor vaccine immunogenicity. However, despite these considerations, vaccine responses are generally considered clinically sufficient. Ideally, immunosuppressed AIIRD patients should receive vaccinations at least two weeks before commencing immunosuppressive treatment. However, it is common for many patients to already be on immunosuppressants during the immunization process. Vaccination rarely triggers flares in AIIRDs; if flares occur, they are typically mild. Despite the heightened infection risk, including COVID-19, among AIIRD patients with rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, and other diseases on immunosuppressants, the vaccination rates remain suboptimal. The future directions of vaccination in the era of immunosuppression will likely involve customized vaccines with enhanced adjuvants and alternative delivery methods. By addressing the unique challenges faced by immunosuppressed individuals, we may improve vaccine efficacy, reduce the risk of infections, and ultimately enhance the health outcomes. Additionally, clinical trials to evaluate the safety and efficacy of temporarily discontinuing immunosuppressants during vaccination in various AIIRDs are crucial.

Facilitators and barriers of vaccine uptake in patients with autoimune inflammatory rheumatic disease: a scoping review

OBJECTIVES

Patients with autoimmune inflammatory rheumatic diseases (AIRD) often have lower vaccination coverage rates compared with the general population, despite being disproportionately affected by infectious complications. We aim to systematically review the literature regarding vaccination willingness and hesitancy in AIRD.

METHODS

A scoping review was conducted in PubMed, EMBASE and the Cochrane Library in June 2021. Study selection was performed by two independent reviewers and data were extracted using a standardised form. Risk of bias was assessed using instruments from McMaster University. Identified barriers were categorised into the WHO's measuring behavioural and social drivers (BeSD) of vaccination conceptual model.

RESULTS

The search yielded 1644 hits of which 30 publications were included (cross-sectional studies based on interviews (n=27) and intervention studies (n=3)). The majority of studies reported barriers to influenza and pneumococcal vaccination only (n=9) or in combination with another vaccination (n=8) from the patients' perspective. Only one study assessed the view of rheumatologists. Coverage of domains matched to the BeSD model suggests a lack of awareness of infection risk by both patients and physicians. Patients mainly mentioned behavioural and social factors that negatively influenced their willingness to be vaccinated while physicians mentioned organisational deficits as major barriers.

CONCLUSIONS

The view on vaccination in patients with AIRD diverges between patients and rheumatologists. Our results show that in-depth counselling on vaccines is important for patients, whereas physicians need support in implementing specific immunisation recommendations. The themes identified provide a starting point for future interventions to improve vaccine rates in patients with AIRD.

Effectiveness of an intervention to overcome influenza vaccine hesitancy in specialty clinic patients

BACKGROUND

Individuals on immunosuppressive therapies experience greater morbidity and mortality due to vaccine-preventable illnesses, but there are low rates of adherence to immunization guidelines within this population.

OBJECTIVE

To determine the effectiveness of clinician-led education, patient-centered dialogue, and immediately available immunization on influenza vaccination uptake in patients taking immunosuppressive therapies.

METHOD

We used a controlled before-and-after quasi-experimental design to evaluate our quality improvement intervention occurring from September 2019 to March 2020, with follow-up through July 2020. The study included 2 dermatology practices wherein nursing staff offered influenza vaccination during patient rooming (standard care). Within each practice, clinicians either implemented the intervention or provided only standard care. Patients received the intervention or standard care depending on the clinician they visited. Patients seen at the 2 clinics during the intervention period were included in analyses if they were taking or newly prescribed immunosuppressant medication at the time of their visit. We examined influenza immunization status for 3 flu seasons: 2017-2018 (preintervention), 2018-2019 (preintervention), and 2019-2020 (intervention).

INTERVENTION

Immunosuppressed patients initially declining an influenza vaccine were provided dermatologist-led education on the benefits of immunization. Dermatologists explored and addressed individual patients' immunization concerns. Influenza vaccination was then offered immediately postdialogue.

RESULTS

Analyses included 201 dermatology patients who were prescribed or currently taking immunosuppressive medication (intervention group [72.6%], comparison group [27.4%]). During the intervention period, 91.1% of the intervention group received influenza vaccination compared to 56.4% of the comparison group. Vaccination trends from 2018-2019 (preintervention) to 2019-2020 (intervention) differed significantly between groups (χ2 = 22.92, P < .001), with greater improvement in the intervention group. In 2019-2020, influenza vaccination was more likely in the intervention group relative to the comparison group (odds ratio: 16.22, 95% confidence interval: 5.55-47.38). In the subset of patients that had never received an influenza vaccine, influenza immunization in 2019-2020 was more common in the intervention group (75.8%, 25/33) relative to the comparison group (13.3%, 2/15, P < .001).

CONCLUSION

The intervention successfully addressed vaccine hesitancy and improved influenza immunization rates in an immunosuppressed population receiving care from a specialty clinic. Implementing a similar model across specialty clinics may improve vaccination rates for influenza, coronavirus disease 2019, and other vaccine-preventable illnesses in other populations.

Predictors of Influenza Vaccination in Early Rheumatoid Arthritis 2017-2021: Results From the Canadian Early Arthritis Cohort

Objective

Adults with rheumatoid arthritis (RA) are at a higher risk for infections, including influenza and related complications. We identified influenza vaccination coverage in adults newly diagnosed with RA and examined sociodemographic RA characteristics and attitudes associated with vaccination.

Methods

We used data from patients enrolled in the Canadian Early Arthritis Cohort between September 2017 and February 2021. At enrollment, participants reported their vaccination status in the previous year and completed the Beliefs About Medicines Questionnaire (BMQ). Clinical data were obtained from medical records. Logistic regression was used to identify predictors of vaccination in the year after RA diagnosis.

Results

The baseline analytic sample of 431 patients were mostly White (80%) women (67%) with a mean age of 56 (SD 14) years. Prediagnosis, influenza vaccine coverage was 38%, increasing to 46% post diagnosis in the longitudinal sample (n = 229). Participants with previous influenza vaccination (odds ratio [OR] 15.33; 95% confidence interval [CI] 6.37‐36.90), on biologics or JAKs (OR 5.42; 95% CI 1.72‐17.03), and with a higher change in BMQ Necessity‐Concerns Differential scores (OR 1.08; 95% CI 1.02‐1.15) had greater odds, whereas women (OR 0.32; 95% CI 0.14‐0.71), participants with a non‐White racial background (OR 0.13; 95% CI 0.04‐0.51), and participants currently smoking (OR 0.09; 95% CI 0.02‐0.37) had lower odds of influenza vaccine coverage.

Conclusion

Influenza vaccination coverage in patients with early RA remains below national targets in adults living with a chronic condition. Discussing vaccine history and medication attitudes at initial clinic visits with new patients with RA may enhance vaccine acceptance and uptake.

Influenza Vaccine Hesitancy and Its Determinants Among Rheumatology Patients

Objective

Patients with rheumatic disease (RD) have an increased risk of influenza and its complications. Despite inactivated influenza vaccine (IIV) recommendations, IIV uptake in patients with RD is suboptimal, a problem of increasing importance in the COVID‐19 era. We estimated the frequency of IIV hesitancy and associated factors among Canadian patients with RD.

Methods

A cross‐sectional vaccine hesitancy survey was completed by rheumatology clinic patients (November 2019 to January 2020). Patients rated their likelihood of receiving the influenza vaccine (scale of 0‐10). We categorized these as follows: likely to refuse (scale of 0‐2), uncertain (scale of 3‐7), or likely to accept (scale of 8‐10). Multivariate logistical regression was used to evaluate factors associated with vaccine hesitancy.

Results

A total of 282 patients (63.5% of those approached) completed the survey, with 165 (58.5%) being likely to accept, 67 (23.8%) being likely to refuse, and 50 (17.7%) uncertain. Uncertain patients were younger and more likely to be employed than those in the other two groups. No previous influenza vaccination (odds ratio [OR] 36.6, 95% confidence interval [CI] 5.3‐252.9), belief that vaccination should not be mandatory (OR 0.1, 95% CI 0.0‐0.7), unwillingness to take time off work to be vaccinated (OR 6.8, 95% CI 1.5‐30.6), and distrust in pharmaceutical companies (OR 41.0, 95% CI 5.6‐301.5) predicted likeliness to refuse. Reluctance to pay for vaccination (OR 2.8, 95% CI 1.1‐7.5) and no previous influenza vaccination (OR 18.9, 95% CI 3.3‐109.7) predicted uncertainty.

Conclusion

More than 40% of rheumatology patients are either likely to refuse or uncertain about receiving IIV. This contributes to suboptimal vaccine coverage in this population. Interventions addressing these concerns are needed, particularly in the COVID‐19 era.

Knowledge and attitudes about influenza vaccination in rheumatic diseases patients

Patients with rheumatic diseases (RD) have a higher risk of morbidity and mortality from vaccine-preventable infections attributed to disease activity, comorbidities, immunosuppressive therapy, and other factors. Vaccines are one of the safest and most effective public health interventions. The aim of this study was to investigate knowledge and attitudes about influenza vaccination as factors influencing vaccine uptake and hesitancy in a population with RD. A descriptive cross-sectional study was designed. A self-administered questionnaire surveyed age, RD diagnosis, ten questions about the uptake, safety and efficacy of influenza vaccine, knowledge of cost-free availability, and the relationship between influenza vaccination and RD. A total of 223 questionnaires were filled; 79.8% of patients were vaccinated for influenza at least once. Uptake by diagnosis was 80.3% in rheumatoid arthritis, 76.2% in osteoarthritis, 86.7% in lupus, 73.9% in other auto-immune diseases (AID), and 60% in other non-AID; 83.9% of patients considered influenza vaccine as safe and effective. From those who had never been vaccinated, 26.7% of patients did not consider influenza vaccine safe and effective vs. 13.5% among patients who had been vaccinated (P = .032). Only 7.6% considered that RD patients could not be vaccinated; 11.7% thought that influenza vaccine would worsen their RD symptoms. This study showed that concerns about safety, efficacy, side effects, fear of the vaccine, and knowledge of cost diminished vaccine uptake. These are factors related to confidence, complacency, and convenience as components of vaccine hesitancy that affect influenza vaccination in RD patients.

Knowledge and attitudes about influenza vaccination in rheumatic diseases patients

Patients with rheumatic diseases (RD) have a higher risk of morbidity and mortality from vaccine-preventable infections attributed to disease activity, comorbidities, immunosuppressive therapy, and other factors. Vaccines are one of the safest and most effective public health interventions. The aim of this study was to investigate knowledge and attitudes about influenza vaccination as factors influencing vaccine uptake and hesitancy in a population with RD. A descriptive cross-sectional study was designed. A self-administered questionnaire surveyed age, RD diagnosis, ten questions about the uptake, safety and efficacy of influenza vaccine, knowledge of cost-free availability, and the relationship between influenza vaccination and RD. A total of 223 questionnaires were filled; 79.8% of patients were vaccinated for influenza at least once. Uptake by diagnosis was 80.3% in rheumatoid arthritis, 76.2% in osteoarthritis, 86.7% in lupus, 73.9% in other auto-immune diseases (AID), and 60% in other non-AID; 83.9% of patients considered influenza vaccine as safe and effective. From those who had never been vaccinated, 26.7% of patients did not consider influenza vaccine safe and effective vs. 13.5% among patients who had been vaccinated (P = .032). Only 7.6% considered that RD patients could not be vaccinated; 11.7% thought that influenza vaccine would worsen their RD symptoms. This study showed that concerns about safety, efficacy, side effects, fear of the vaccine, and knowledge of cost diminished vaccine uptake. These are factors related to confidence, complacency, and convenience as components of vaccine hesitancy that affect influenza vaccination in RD patients.

A clinical audit of pneumococcal vaccination among patients with autoimmune rheumatic diseases living in Greece: The power of awareness

INTRODUCTION

Patients with autoimmune rheumatic diseases (ARDs) are at increased risk for pneumococcal infections and should be vaccinated against Streptococcus pneumoniae. Data on the rates of pneumococcal vaccination among patients with ARDs in Southern Europe are scarce. Here, we estimate the pneumococcal vaccination rate in patients living in Greece with ARDs, explore the patients' awareness regarding vaccination, and try to recognize factors that influence the vaccine uptake.

METHODS

Between October 2015 and September 2016, a structured questionnaire was provided to all consecutive patients with ARDs attending one outpatient clinic of our department. The survey included parameters concerning patients' demographics, underlying ARD and immunosuppressive medications, other comorbidities, vaccine type, knowledge about infection risk and necessity of vaccination. Univariate and multivariate analyses were performed to study any association of these factors with the vaccination uptake.

RESULTS

Overall, 395 patients with ARDs (30.13% aged >65 years and 78.99% female) participated in our survey. The most frequent ARD was rheumatoid arthritis (43.04%); 40.51% of patients were receiving biologic agents and 44.56% steroids. Pneumococcal vaccination rate was 49.37%, while 45.06% of patients have been vaccinated during the last five years and only 8.21% of them had a second pneumococcal vaccine, as per national guidelines. The decision of vaccination was significantly influenced by the patient's age (>65 years) (p < 0.001) and the complete awareness of reasons for being vaccinated (p < 0.001), but not by presence of comorbidities, the type of ARD or administration of a biologic agent. The main reason for no vaccination was that it was not suggested by the caring physician (82.50%).

CONCLUSIONS

In our cohort of patients with ARDs the pneumococcal vaccination was suboptimal. Better understanding of the significance of vaccination by the patient and suggestion for vaccination by the caring physician will improve vaccination uptake and optimize the clinical benefits among patients with ARDs.

Using Lean Six Sigma to Improve Pneumococcal Vaccination Rates in a Veterans Affairs Rheumatology Clinic

Pneumonia is a major cause of morbidity and mortality in the United States. Therefore, prevention of pneumococcal pneumonia by administering effective and well-tolerated vaccines is an important goal, especially in the immunocompromised patients who are at an increased risk of infections. At a large Midwestern Veterans Affairs Rheumatology Clinic, an internal audit revealed a baseline immunization rate of 3%. Through the Lean Six Sigma approach, the investigators sought to increase the rate to 70%. An interprofessional approach incorporating provider education, reinforcement at the point of care, and workflow simplification was sequentially implemented. Lean Six Sigma tools, including process mapping, voice of the customer, and statistical process control charts were utilized. These interventions increased the percentage of eligible patients receiving vaccinations from 3% (n = 19/687) to 23% (n = 11/48) and decreased the vaccine administration time from 15 to 7 minutes. No adverse reactions were reported. This was balanced by an increase in appointment time by 4 minutes in those who received vaccines. The Lean Six Sigma approach was critical to reducing waste and improving value for patients and providers by increasing pneumococcal vaccination rates among the immunocompromised veteran population in a Midwestern Veterans Affairs Rheumatology Clinic.

Determinants of Vaccination Uptake in Risk Populations: A Comprehensive Literature Review

Vaccination uptake has decreased globally in recent years, with a subsequent rise of vaccine-preventable diseases. Travellers, immunocompromised patients (ICP), and healthcare workers (HCW) are groups at increased risk for (severe) infectious diseases due to their behaviour, health, or occupation, respectively. While targeted vaccination guidelines are available, vaccination uptake seems low. In this review, we give a comprehensive overview of determinants-based on the integrated change model-predicting vaccination uptake in these groups. In travellers, low perceived risk of infection and low awareness of vaccination recommendations contributed to low uptake. Additionally, ICP were often unaware of the recommended vaccinations. A physician's recommendation is strongly correlated with higher uptake. Furthermore, ICP appeared to be mainly concerned about the risks of vaccination and fear of deterioration of their underlying disease. For HCW, perceived risk of (the severity of) infection for themselves and for their patients together with perceived benefits of vaccination contribute most to their vaccination behaviour. As the determinants that affect uptake are numerous and diverse, we argue that future studies and interventions should be based on multifactorial health behaviour models, especially for travellers and ICP as only a limited number of such studies is available yet.

Understanding factors associated with vaccine uptake and vaccine hesitancy in patients with rheumatoid arthritis: a scoping literature review

Due to higher risk of complications associated with vaccine-preventable infections (e.g., influenza, pneumococcus), patients with rheumatoid arthritis (RA) are a priority group for vaccination. However, vaccination rates among RA patients are low, indicating a need to understand the determinants of vaccine hesitancy in this group. This study conducted an evidence synthesis of various stakeholders' (patients, physicians/rheumatologists) perspectives about the determinants of vaccine hesitancy and uptake among patients with RA. We searched three bibliographic and reference databases (PUBMED, PsychINFO, and SCOPUS) for relevant English or French articles published in peer-reviewed journals through July 2019 that conducted either qualitative or quantitative assessments of vaccine hesitancy or uptake. Key themes associated with vaccination hesitancy themes according to different stakeholders were extracted and summarized. Of 783 unique citations, 16 articles met the inclusion criteria. Most studies (78%; n = 134,787 RA patients) examined barriers reported by patients, 13% (n = 114) by rheumatologists. Two principal themes and six sub-themes associated with vaccination hesitancy were identified among both patients and rheumatologists: 'social and contextual factors' (including healthcare policies, access to care/high patient loads, and social/media influences) and 'patient and provider factors' (including patient understanding of benefits and risks, provider awareness of guidelines and perceived responsibility for vaccination, and implementation challenges). Determinants of vaccine hesitancy and uptake in RA identified by different stakeholders implicate patient-, provider-, and healthcare system‑related factors. This information is relevant for the design of interventions that target improving vaccine uptake in RA patients.

Low Influenza, Pneumococcal and Diphtheria-Tetanus-Poliomyelitis Vaccine Coverage in Patients with Primary Sjögren's Syndrome: A Cross-Sectional Study

Objective: To evaluate vaccination coverage and reasons for non-vaccination in patients with primary Sjögren’s syndrome (pSS). Method: A total of 111 patients fulfilling American–European Consensus Group criteria for pSS were interviewed by use of a standardized questionnaire between January 2016 and November 2017 in two French tertiary referral centers for auto-immune diseases. Results: Updated immunization coverage for influenza was 31.5% (n = 35), pneumococcus was 11.7% (n = 13), and diphtheria–tetanus–poliomyelitis (DTP) was 24.3% (n = 27). The main reasons for non-vaccination were fear of side effects from the influenza vaccine (40.3%) and a lack of proposal for the pneumococcal vaccine (72.3%). In vaccinated patients, vaccination was mainly proposed by general practitioners for the influenza vaccine (42.6%) and rheumatologists for the pneumococcal vaccine (41.2%). Probability of influenza vaccination was associated with age (odds ratio/year (OR) 1.04, 95% confidence interval (CI) 1.0–1.1; p = 0.016), history of severe infection (OR 15.9, 95% CI 1.35–186; p = 0.028), low EULAR Sjögren’s syndrome disease activity index (OR 0.85, 95% CI 0.75–0.96; p = 0.013), and comorbidities (OR 3.52, 95% CI 1.22–10.2; p = 0.02). Probability of vaccination against pneumococcus was associated with lung comorbidities (OR 3.83, 95% CI 1.11–13.12; p = 0.033) and up-to-date influenza vaccination (OR 3.71, 95% CI 1.08–12.8; p = 0.038). Conclusion: Influenza, pneumococcal, and DTP vaccine coverage was low in patients with pSS included in this study. These results underline the relevance of systematically screening vaccine status in pSS patients and educating patients and physicians on the need for vaccination to improve vaccine coverage in this population.

A quality improvement intervention failed to significantly increase pneumococcal and influenza vaccination rates in immunosuppressed inflammatory arthritis patients

OBJECTIVES

Pneumococcal and influenza vaccination rates have been suboptimal in studies of immunosuppressed patients. We aimed to assess barriers to and increase rates of 23-valent pneumococcal polysaccharide vaccine (PPSV23) and influenza vaccination in this group. The primary endpoint was a statistically significant increase in adequate PPSV23 and influenza vaccination.

METHODS

In 2017, rheumatology outpatients completed an anonymous questionnaire recording vaccination knowledge, status, and barriers. Simultaneously, a low-cost multifaceted quality improvement (QI) intervention was performed. All outpatients on oral steroids, immunosuppressant conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologics disease-modifying antirheumatic drugs (bDMARDs) were included in the study. In 2018, post-intervention, the clinic was re-assessed. Demographics, diagnosis, medications, smart phone access, and willingness to use this for vaccination reminders were assessed for independent vaccination predictors using binary logistic regression analysis.

RESULTS

Four hundred twenty-five patients were included (72.6% rheumatoid arthritis, 74% women, 45.6% ≥ 60 years old). From 2017 to 2018, PPSV23 vaccination rates changed from 41.0 to 47.2% (P = 0.29) and influenza from 61.8 to 62.1% (P = 0.95). The most common reason for non-vaccination was lack of awareness. Following the intervention, this changed for influenza (36.7 to 34.2%) and PPSV23 (82.1 to 76.4%). General practitioners performed most vaccinations, only 3.6% were delivered in the hospital. Significant predictors of PPSV23 vaccination were older age {≥ 80 years had an OR 41.66 (95% CI 3.69-469.8, P = 0.003), compared with ≤ 39 years}, bDMARD use (OR 2.80, 95% CI 1.24-6.32, P = 0.013), and adequate influenza vaccination (OR 9.01, 95% CI 4.40-18.42, P < 0.001). Up-to-date PPSV23 vaccination (OR 8.93, 95% CI 4.39-18.17, P < 0.001) predicted influenza vaccination.

CONCLUSIONS

PPSV23 and influenza vaccination rates were suboptimal. The intervention did not cause a statistically significant change in vaccination rates. Point-of-care vaccination may be more effective.Key Points• Low vaccination rates amongst immunosuppressed inflammatory arthritis outpatients• Less than 5% of vaccinations occurred in hospital• There was no statistically significant difference in the rates of adequate PPSV23 (41.0 to 47.2%) or influenza (61.8 to 62.1%) vaccination following our intervention.

Vaccination against influenza and pneumococcal infections in patients with autoimmune disorders under biological therapy: Coverage and attitudes in patients and physicians

BACKGROUND

Patients under biological therapy for auto-immune disease are considered immunosuppressed and several recent recommendations highlight the need for vaccination against influenza and pneumococcal infections. The aims of this study were to evaluate influenza and pneumococcal vaccine coverage among patients receiving biological therapy and identify factors associated with vaccine uptake within this population.

METHODS

A retrospective cross-sectional study was performed in adult patients attending hospitals for an auto-immune/inflammatory disease and treated with biological therapy. Vaccine uptake was evidenced from patient's medical records or from their pharmacist's records. Questionnaires about attitudes and knowledge regarding vaccinations were administered to patients and their physicians. Multivariable logistic regression was used to determine factors significantly associated with influenza and pneumococcal vaccine receipt.

RESULTS

A total of 208 patients were included: 52% female and mean age 50.6 (± 14.7) years. Among them 173 completed the questionnaire while 72 physicians replied. Underlying inflammatory diseases were rheumatisms (46%), bowel diseases (31%) and skin diseases (23%). Vaccine uptake was 28% for influenza, 48% for pneumococcus and 22% received both vaccines. Main factors associated to positive uptake were receiving a prescription from a physician, as well as having a good knowledge of vaccines. Factors limiting vaccination were a negative attitude toward vaccines in general, and belonging to the group of inflammatory bowel diseases.

CONCLUSIONS

Vaccine coverage for influenza and pneumococcal infections are low in the patients under biologics for auto-immune/inflammatory disease. Health policies should reinforce information and promotion of these vaccines among these patients but also the prescribers.

Suboptimal Immunization Coverage among Canadian Rheumatology Patients in Routine Clinical Care

OBJECTIVE

To assess vaccination coverage and predictors of vaccination among a Canadian population of rheumatology patients in routine clinical care.

METHODS

In this cross-sectional study, consecutive adult patients presenting to a tertiary rheumatology clinic at the McGill University Health Center between May and September 2015 were asked to fill a survey on vaccination. Patients self-identified as having rheumatoid arthritis (RA), systemic autoimmune rheumatic diseases (SARD), spondyloarthropathies (SpA), or other diseases (OD). Multivariate logistical regression analyses were performed to evaluate patient and physician factors associated with various vaccinations [for influenza, pneumococcus, and hepatitis B virus (HBV)]. Published Quebec general population influenza and pneumococcal vaccination rates in those aged ≥ 65 years were used as comparative baseline rates.

RESULTS

Three hundred fifty-two patients were included in the analysis (RA: 136, SARD: 113, SpA: 47, OD: 56). Vaccination rates were reported as follows: (1) influenza: RA 48.5%, SARD 42.0%, SpA 31.9%, OD 88.9%, Quebec general population 58.5%; (2) pneumococcal: RA 42.0%, SARD 37.8%, SpA 29.7%, OD 33.3%, Quebec general population 53.2%; (3) HBV: RA 33.6%, SARD 55.6%, SpA 73.5%, OD 36.8%; and (4) herpes zoster: RA 5.6%, SARD 28.6%, SpA 25.0%, OD 16.7%. Physician recommendation was the strongest independent predictor of vaccination across all vaccine types (influenza: OR 8.56, 95% CI 2.80-26.2, p < 0.001; pneumococcal: OR 314, 95% CI 73.0-1353, p < 0.001; HBV: OR 12.8, 95% CI 5.27-31.1, p < 0.001). Disease group, disease duration, comorbidities, treatment type, and being followed by a primary care physician were not significantly associated with vaccination.

CONCLUSION

There is suboptimal immunization coverage among ambulatory rheumatology patients. An important role for patient and physician education is highlighted in our study, especially because physician recommendation of vaccination was strongly predictive of vaccine uptake.

Predictors and temporal trend of flu vaccination in auto-immune rheumatic diseases in the UK: a nationwide prospective cohort study

Objectives

To examine temporal trend in uptake of seasonal influenza vaccine (SIV) in the UK and explore disease and demographic factors associated with vaccination.

Methods

From the Clinical Practice Research Datalink, 32 751 people with auto-immune rheumatic diseases prescribed DMARDs between 2006 and 2016 were identified. The proportion vaccinated between 1 September of one year and 31 March of the next year was calculated and stratified by age, other indications for vaccination, auto-immune rheumatic diseases type and number of DMARDs prescribed. Stata and Joinpoint regression programs were used.

Results

SIV uptake was high in those aged ⩾65 years (82.3 and 80.7% in 2006–07 and 2015–16, respectively). It was significantly lower in other age groups, but improved over time with 51.9 and 61.9% in the 45–64 year age group, and 32.3 and 50.1% in the <45 year age group being vaccinated in 2006–07 and 2015–16, respectively. While 64.9% of the vaccinations in those ⩾65 years old occurred by 3 November, in time to mount a protective immune response before the influenza activity becomes substantial in the UK, only 38.9% in the 45–64 year and 26.2% in the <45 year age group without any other reason for vaccination received SIV by this date. Women, those with additional indications for vaccination, on multiple DMARDs and with SLE were more likely to be vaccinated.

Conclusion

SIV uptake is low in the under 65s, and the majority of them are not vaccinated in time. Additional effort is required to promote timely uptake of SIV in this population.

Anti-polysaccharide and anti-diphtheria protective antibodies after 13-valent pneumococcal conjugate vaccination in rheumatoid arthritis patients under immunosuppressive therapy

Immunogenicity of 13-valent pneumococcal polysaccharide (PnPS) conjugate vaccine (PCV13) was evaluated in 38 rheumatoid arthritis patients under immunosuppressive treatment and 20 healthy controls (HC). Antibodies to all PnPS and diphtheria-toxin analogue conjugate protein were measured pre- (T0), 1 (T1), 6 (T2), 12 (T3) months post-immunization. Patients and HC had similar response to individual PnPS. Mean antibody levels to all PnPS but one doubled at T1 compared with T0, with T3 persistence for only 8-7/13 PnPS. Baseline antibody levels was inversely associated with the rate of responders at T1 (T1/T0≥2) to 11/13 PnPS. Few subjects reached protective IgG levels against some serotypes frequently isolated in Italian patients with invasive pneumococcal disease. Antibody response was not influenced by therapy, except the one to PS7F, which was reduced by tumor necrosis factor-α-inhibitors. Vaccination increased also anti-diphtheria IgG. Despite this study substantially confirmed the PCV13 immunogenicity in immunocompromised patients, it also revealed some limitations.

[Influenzae and pneumococcal vaccination rate in an internal medicine ward]

INTRODUCTION

Vaccination against influenza virus and Streptococcus pneumoniae is a global health priority and authorities, on the basis of recent publications, have recently updated French recommendations. The aim of this study was to describe the influenzae and pneumococcal vaccination's rate in an internal medicine ward.

MATERIAL AND METHODS

All patients consecutively hospitalized during a 10 week-period in an internal medicine ward were included. The reasons for non-vaccination and the impact of an educational program for corrective measures were reported.

RESULTS

Overall, 198 consecutive patients were included; 93 (47%) were immunocompromised; 142 (71.2%) had an indication for pneumococcal vaccination and 171 (86.4%) for influenza vaccination but only 16.2% and 55% of them were vaccinated against these microorganisms, respectively. Prior pneumococcal vaccination was more frequently observed in immunocompromised patients than in non-immunocompromised patients (21.1 versus 6.4%; P=0.029), but no significant difference was observed for influenza vaccine. Corrective measures were initiated in 46 patients (39%), non-immunized against S. pneumoniae.

CONCLUSION

These results underline the very low prevalence of pneumococcal vaccination rate in at-risk hospitalized patients, as compared with influenza, despite recent recommendations.

Barriers of Influenza Vaccination Intention and Behavior - A Systematic Review of Influenza Vaccine Hesitancy, 2005 - 2016

BACKGROUND

Influenza vaccine hesitancy is a significant threat to global efforts to reduce the burden of seasonal and pandemic influenza. Potential barriers of influenza vaccination need to be identified to inform interventions to raise awareness, influenza vaccine acceptance and uptake.

OBJECTIVE

This review aims to (1) identify relevant studies and extract individual barriers of seasonal and pandemic influenza vaccination for risk groups and the general public; and (2) map knowledge gaps in understanding influenza vaccine hesitancy to derive directions for further research and inform interventions in this area.

METHODS

Thirteen databases covering the areas of Medicine, Bioscience, Psychology, Sociology and Public Health were searched for peer-reviewed articles published between the years 2005 and 2016. Following the PRISMA approach, 470 articles were selected and analyzed for significant barriers to influenza vaccine uptake or intention. The barriers for different risk groups and flu types were clustered according to a conceptual framework based on the Theory of Planned Behavior and discussed using the 4C model of reasons for non-vaccination.

RESULTS

Most studies were conducted in the American and European region. Health care personnel (HCP) and the general public were the most studied populations, while parental decisions for children at high risk were under-represented. This study also identifies understudied concepts. A lack of confidence, inconvenience, calculation and complacency were identified to different extents as barriers to influenza vaccine uptake in risk groups.

CONCLUSION

Many different psychological, contextual, sociodemographic and physical barriers that are specific to certain risk groups were identified. While most sociodemographic and physical variables may be significantly related to influenza vaccine hesitancy, they cannot be used to explain its emergence or intensity. Psychological determinants were meaningfully related to uptake and should therefore be measured in a valid and comparable way. A compendium of measurements for future use is suggested as supporting information.

A large two-centre study in to rates of influenza and pneumococcal vaccination and infection burden in rheumatoid arthritis in the UK

BACKGROUND

Infections are a common complication of RA with associated morbidity and mortality. The aetiology of increased risk is complex and multifactorial. Despite this, strategies to mitigate against risk of infection including vaccination are not always addressed in primary or secondary care with wide variation in practice from multiple small single centre audits. This study was a large two-centre survey of vaccine uptake in routine clinical practice and evaluated the relationship between vaccination and the burden of infection in RA patients.

METHODS

A patient questionnaire was devised and disseminated through postal, clinic and phone survey at 2 UK rheumatology centres, detailing past vaccination history, reasons for non-vaccination, and history of recent infection. In a subset of patients, primary care vaccination data were also obtained.

RESULTS

In total 929 patients responded to the survey. Over 85 % of patients were vaccinated against influenza, however only 44 % were vaccinated against pneumococcus. The vast majority of vaccination was undertaken in primary care. In the 12 months prior to the survey, 7.7 % of subjects recalled at least one episode of severe infection requiring admission, and nearly 40 % reported receiving at least one course of antibiotics.

CONCLUSIONS

Infections are common in RA and Rheumatologists need to be adept at recognising at risk patients and managing them appropriately. Influenza vaccination uptake is good whilst pneumococcal vaccination rates are comparatively poor. Collaborative approaches between primary and secondary care are required to maximise vaccine uptake, which is safe and recommended in RA patients.

Influenza and Pneumococcal Vaccination Uptake in Patients with Rheumatoid Arthritis Treated with Immunosuppressive Therapy in the UK: A Retrospective Cohort Study Using Data from the Clinical Practice Research Datalink

INTRODUCTION

Guidelines for the management of rheumatoid arthritis (RA) recommend using influenza and pneumococcal vaccinations to mitigate infection risk. The level of adherence to these guidelines is not well known in the UK. The aims of this study were to describe the uptake of influenza and pneumococcal vaccinations in patients with RA in the UK, to compare the characteristics of those vaccinated to those not vaccinated and to compare vaccination rates across regions of the UK.

METHODS

A retrospective cohort study of adults diagnosed with incident RA and treated with non-biologic immunosuppressive therapy, using data from a large primary care database. For the influenza vaccination, patients were considered unvaccinated on 1st September each year and upon vaccination their status changed to vaccinated. For pneumococcal vaccination, patients were considered vaccinated after their first vaccination until the end of follow-up. Patients were stratified by age 65 at the start of follow-up, given differences in vaccination guidelines for the general population.

RESULTS

Overall (N=15,724), 80% patients received at least one influenza vaccination, and 50% patients received a pneumococcal vaccination, during follow-up (mean 5.3 years). Of those aged below 65 years (N=9,969), 73% patients had received at least one influenza vaccination, and 43% patients received at least one pneumococcal vaccination. Of those aged over 65 years (N=5,755), 91% patients received at least one influenza vaccination, and 61% patients had received at least one pneumococcal vaccination. Those vaccinated were older, had more comorbidity and visited the GP more often. Regional differences in vaccination rates were seen with the highest rates in Northern Ireland, and the lowest rates in London.

CONCLUSIONS

One in five patients received no influenza vaccinations and one in two patients received no pneumonia vaccine over five years of follow-up. There remains significant scope to improve uptake of vaccinations in patients with RA.

A Multifaceted Intervention to Improve Influenza, Pneumococcal, and Herpes Zoster Vaccination among Patients with Rheumatoid Arthritis

OBJECTIVE

Vaccination rates for influenza, pneumococcus, and zoster in patients with rheumatoid arthritis (RA) have remained low. Simple electronic or paper reminders have produced only small increases in vaccination rates. We sought to identify a more effective approach to improve vaccination rates.

METHODS

We conducted a system-level intervention at an academic rheumatology clinic that included electronic reminders with linked order sets, physician auditing and feedback, patient outreach, and optional printed prescriptions for zoster vaccination at an outside pharmacy.

RESULTS

We targeted 1255 eligible patients with RA. There was no change in patients' self-reported influenza vaccination rates, although the baseline self-reported rate was already high and much higher than that documented in the electronic health record. Pneumococcal vaccination rates increased from 28.7% to 45.8%; in regression analysis, the rate of change in pneumococcal vaccination increased by 9.4% per year above baseline trends (95% CI 3.9-15.5, p = 0.002). The rate of zoster vaccination increased from 2.5% to 4.5% overall (p = 0.01) and from 3.0% to 6.6% among patients not receiving biologic therapy that precluded zoster vaccination.

CONCLUSION

Although the intervention improved pneumococcal and zoster vaccination rates, the improvement in pneumococcal vaccination rate was less than expected, and the zoster vaccination rate remained low even for ideal candidates. Likely barriers include lack of familiarity and difficulty using electronic reminders and order sets, uncertainty about the value and safety of recommended vaccines, and uncertainty about patients' insurance coverage and prior vaccination history. Future interventions should include strategies to address these.

Autoimmune disease and vaccination: impact on infectious disease prevention and a look at future applications

Vaccines hold promise both for the prevention of infections and as potential immunologic therapy for patients with autoimmune disease (AD). These patients are at high risk for both common and opportunistic infections, but this risk can be significantly reduced and even obviated with the use of recommended available vaccines. Unfortunately, patients with ADs are not routinely offered or provided indicated vaccinations and have higher rates of complications from vaccine-preventable illnesses than patients without ADs. In addition, vaccine therapy is currently under study for the treatment of autoimmune disorders, with early studies demonstrating immunomodulatory effects that may counter undesired immune activation and alleviate disease activity.

Influenza and pneumococcal vaccine coverage in 584 patients taking biological therapy for chronic inflammatory joint: A retrospective study

OBJECTIVES

To evaluate influenza and pneumococcal vaccine coverage in patients taking biological therapy for chronic inflammatory joint disease and to identify factors associated with the decision to administer these two vaccines.

METHODS

Retrospective cross-sectional questionnaire study of a cohort of 584 patients taking biological therapy for chronic inflammatory joint disease (rheumatoid arthritis or spondyloarthritis). We studied the influenza and pneumococcal vaccine coverage rates, information about these vaccines given to patients by the primary-care physician and rheumatologist, and reasons for not administering the vaccines.

RESULTS

Overall vaccine coverage rates were 44% for influenza and 62% for pneumococcus. Factors associated with being vaccinated were patient age, previous influenza vaccination, and patient information. Concern about adverse effects and absence of patient information by the primary-care physician and rheumatologist were associated with very low coverage rates.

CONCLUSION

This study showed insufficient vaccine coverage rates, particularly against influenza, in a population at high risk because of exposure to biological therapy. Patient information by healthcare professionals about influenza and pneumococcal vaccination has a major impact and should be renewed as often as possible.

Vaccinations in adults with chronic inflammatory joint disease: Immunization schedule and recommendations for patients taking synthetic or biological disease-modifying antirheumatic drugs

The risk of infection associated with autoimmune diseases is further increased by the use of biotherapies. Recommendations to minimize this risk include administering the full complement of vaccines on the standard immunization schedule, as well as the pneumococcal and influenza vaccines. Adults with chronic inflammatory joint disease (IJD) may receive a 13-valent pneumococcal conjugate vaccine, as well as a live attenuated vaccine against recurrent herpes zoster, recently licensed by European regulatory authorities. Live attenuated vaccines can be given only after an interval without immunosuppressant and/or glucocorticoid therapy. The effectiveness of vaccines, as assessed based on titers of protective antibodies, varies across vaccine types and disease-modifying antirheumatic drugs (DMARDs). Thus, methotrexate and rituximab are usually associated with decreased vaccine responses. The risks associated with vaccines are often considerably exaggerated by the media, which serve lobbies opposed to immunizations and make some patients reluctant to accept immunizations. Increasing immunization coverage may diminish the risk of treatment-related infections. A physician visit dedicated specifically to detecting comorbidities in patients with chronic IJD may result in improved immunization coverage. In this review, we discuss immunizations for adults with chronic IJD based on the treatments used, as well as immunization coverage. Many questions remain unanswered and warrant investigation by studies coordinated by the French networks IREIVAC (Innovative clinical research network in vaccinology) and IMIDIATE (Immune-Mediated Inflammatory Disease Alliance for Translational and Clinical Research).

Attitude, knowledge and factors associated with influenza and pneumococcal vaccine uptake in a large cohort of patients with secondary immune deficiency

BACKGROUND

Immunocompromised patients are at increased risk for severe influenza and invasive pneumococcal diseases. Population-specific vaccine recommendations are thus warranted. This study aimed to estimate the prevalence and predictors of influenza and pneumococcal vaccine uptake in a large cohort of patients with secondary immune deficiency.

METHODS

An anonymous online survey was submitted to the members of 11 French associations of immunocompromised patients. The questionnaire included questions concerning underlying disease, care and treatment, flu and pneumococcal vaccine uptake, attitudes and knowledge about vaccination. Factors associated with vaccine uptake were assessed by multivariate logistic regression.

RESULTS

Among the 10,897 solicited patients, 3653 agreed to participate (33.5%): 75% were female, 20% aged 65+, 79% were followed for an autoimmune disease, 13% were solid organ recipients or waiting for transplantation and 8% were treated for hematological malignancies. 3109 (85%) participants were treated with immunosuppressive therapy. Self-reported vaccine uptake was 59% (95%CI [57-60]) against seasonal influenza and 49% (95%CI [47-50]) against pneumococcal diseases. Better knowledge of and favorable attitudes toward vaccination were positively associated with vaccine uptake while being treated with a biological therapy was negatively associated.

CONCLUSION

Despite specific recommendations regarding immunocompromised patients, influenza and pneumococcal vaccination rates do not reach recommended levels. Targeted information campaigns on vaccination toward these populations should be implemented to improve vaccine coverage and thus reduce the burden of infections.

Role of vaccinations and prophylaxis in rheumatic diseases

Targeted strategies for reducing the increased risk of infection in patients with autoimmune rheumatic diseases include vaccinations as well as antibiotic prophylaxis in selected patients. However, there are still issues under debate: Is vaccination in patients with rheumatic diseases immunogenic? Is it safe? What is the impact of immunosuppressive drugs on vaccine immunogenicity and safety? Does vaccination cause disease flares? In which cases is prophylaxis against Pneumocystis jirovecii required? This review addresses these important questions to which clinicians and researchers still do not have definite answers. The first part includes immunization recommendations and reviews current data on vaccine efficacy and safety in patients with rheumatic diseases. The second part discusses prophylaxis for Pneumocystis pneumonia.

Influenza vaccination rate among patients with moderate to severe psoriasis

BACKGROUND

Patients with chronic inflammatory diseases such as psoriasis vulgaris represent a risk group for developing serious complications after influenza virus infection. By vaccinating this cohort such complications might be prevented. The objective was to determine the vaccination rate among patients with moderate to severe psoriasis and to explore the surrounding circumstances.

PATIENTS AND METHODS

A nationwide, non-interventional, cross-sectional study was performed in 1,229 adults with confirmed psoriasis or psoriatic arthritis. The survey consisting of 15 questions about vaccination and vaccination adherence was distributed to patients enrolled in the psoriasis patient registry "PsoBest".

RESULTS

About 28 % of the patients (95 %-CI 24.0-31.6) were vaccinated. The mean age was 58 years, 40 % were females. The prevalence of psoriatic arthritis was 28 % at baseline and 39 % during the vaccination period. General practitioners vaccinated 50 % of the patients, while dermatologists suggested vaccination in 7 % of the cases. Fifty percent of the patients reported that they had been vaccinated at their own request. 91 % of the patients had been vaccinated at least once over the past ten years, receiving on average 5.9 influenza vaccinations during the decade.

CONCLUSIONS

The vaccination rate in the study cohort was relatively low compared to that in the general population. Influenza vaccination had only been suggested by a small percentage of physicians.

Increasing pneumococcal vaccination for immunosuppressed patients: a cluster quality improvement trial

OBJECTIVE

Pneumococcal vaccination is important for patients taking immunosuppressive medications, but prior studies suggest that most patients do not undergo vaccination. The aim of this study was to evaluate the effects of a point-of-care paper reminder form as a quality improvement (QI) strategy to increase the numbers of immunosuppressed patients being kept up-to-date with pneumococcal vaccination in a rheumatology practice.

METHODS

Selected rheumatologists at 5 ambulatory practice sites received a point-of-care paper reminder form to be applied to patients who were not up-to-date with pneumococcal vaccination. Interrupted time-series analyses were used to measure the effect of the intervention on the pneumococcal vaccination rates among patients, comparing the rates in the intervention group with those in a control group of rheumatologists who did not receive the intervention. Adjusted Cox proportional hazards models were examined to identify independent predictors of being up-to-date with pneumococcal vaccination.

RESULTS

We evaluated a total of 3,717 patients (66.0% with rheumatoid arthritis) who were taking immunosuppressive medications (74.1% women, mean age 53.7 years). Rheumatologists who received the intervention had a significant increase in the rate of patients who were up-to-date with pneumococcal vaccination, from 67.6% to 80.0% (P=0.006), in the time period following the intervention, compared to a rate that remained stable, from 52.3% to 52.0% (P=0.90), among patients in the nonintervention control group during this same time period. In regression models, positive predictors of being up-to-date with pneumococcal vaccination at the patient level included the following: having received the intervention (hazard ratio [HR] 3.58, 95% confidence interval [95% CI] 2.46-5.20), having a primary care physician affiliated with Brigham and Women's Hospital (HR 1.68, 95% CI 1.44-1.97), having a diagnosis of diabetes mellitus (HR 1.57, 95% CI 1.02-2.41), and being age 56-65 years at baseline, compared to age≤45 years (HR 1.24, 95% CI 1.01-1.51).

CONCLUSION

A QI strategy involving a simple point-of-care paper reminder form significantly increased the rate of being up-to-date with pneumococcal vaccination among patients receiving immunosuppressive medications in our rheumatology practices over a 6-month period.

Knowledge, attitudes, and clinical practice of rheumatologists in vaccination of the at-risk rheumatology patient population

BACKGROUND

Patients with inflammatory arthritis are at increased risk of infection. Much of the burden of infection in this population is vaccine preventable. A number of international rheumatology organizations have published expert recommendations for vaccination in adult patients. Despite this, reported vaccination rates remain low among patients with inflammatory arthritis.

OBJECTIVES

We sought to establish the knowledge, attitudes, and clinical practice of rheumatologists with respect to vaccination.

METHODS

Rheumatologists practicing in Ireland in 2009 were surveyed by postal questionnaire. Data collected was entered into Microsoft Excel and statistical analysis was carried out using SPSS18 software.

RESULTS

Eighty (100%) practicing rheumatologists were surveyed. Response rate was 55% (44/80). Of those surveyed, 57% (25/44) had no written departmental vaccination guidelines. Although 90% of those surveyed agreed that the responsibility for ensuring vaccine compliance rests with health professionals, only 5% considered that the rheumatology clinic was the best setting in which to accomplish this. Half (50%, n = 22) of practicing rheumatologists do not inquire about vaccination history in the clinic, with a minority (9%, n = 4) recording vaccination history in their clinical notes. A significant percentage of rheumatologists do not perform screening about prior vaccination before initiation of either anti-tumor necrosis factor (34%) or disease-modifying antirheumatic disease (42%) therapy. Moreover, 57% (n = 25) considered the responsibility for vaccination the domain of the patients' general practitioners with the favored strategy to improve vaccine compliance being led by the primary care physicians (48%, n = 21).

CONCLUSIONS

The practice of Irish rheumatologists with regard to vaccination in this survey was suboptimal. Most neither recommend nor record vaccination history in their clinical notes, with the majority feeling that the rheumatology clinic is not the appropriate setting in which to target strategies to improve vaccine compliance. Although a more proactive role needs to be taken by rheumatologists as the principal prescribers of immunosuppressive therapy on this issue, our survey respondents suggest that strategies to improve vaccine uptake should be developed outside the rheumatology clinic and, in particular, involve primary care. The circulation of currently available international guidelines on vaccination specific for rheumatology patients to primary care physicians should be used to inform practices to ensure improved vaccine compliance.

Influenza vaccination for immunocompromised patients: systematic review and meta-analysis from a public health policy perspective

BACKGROUND

Immunocompromised patients are vulnerable to severe or complicated influenza infection. Vaccination is widely recommended for this group. This systematic review and meta-analysis assesses influenza vaccination for immunocompromised patients in terms of preventing influenza-like illness and laboratory confirmed influenza, serological response and adverse events.

METHODOLOGY/PRINCIPAL FINDINGS

Electronic databases and grey literature were searched and records were screened against eligibility criteria. Data extraction and risk of bias assessments were performed in duplicate. Results were synthesised narratively and meta-analyses were conducted where feasible. Heterogeneity was assessed using I(2) and publication bias was assessed using Begg's funnel plot and Egger's regression test. Many of the 209 eligible studies included an unclear or high risk of bias. Meta-analyses showed a significant effect of preventing influenza-like illness (odds ratio [OR]=0.23; 95% confidence interval [CI]=0.16-0.34; p<0.001) and laboratory confirmed influenza infection (OR=0.15; 95% CI=0.03-0.63; p=0.01) through vaccinating immunocompromised patie nts compared to placebo or unvaccinated controls. We found no difference in the odds of influenza-like illness compared to vaccinated immunocompetent controls. The pooled odds of seroconversion were lower in vaccinated patients compared to immunocompetent controls for seasonal influenza A(H1N1), A(H3N2) and B. A similar trend was identified for seroprotection. Meta-analyses of seroconversion showed higher odds in vaccinated patients compared to placebo or unvaccinated controls, although this reached significance for influenza B only. Publication bias was not detected and narrative synthesis supported our findings. No consistent evidence of safety concerns was identified.

CONCLUSIONS/SIGNIFICANCE

Infection prevention and control strategies should recommend vaccinating immunocompromised patients. Potential for bias and confounding and the presence of heterogeneity mean the evidence reviewed is generally weak, although the directions of effects are consistent. Areas for further research are identified.

Immunology: Prevention of infections in patients with autoimmune diseases

Several new recommendations for the vaccination of adults with autoimmune inflammatory diseases could represent an important step forward in the prevention of infections in these high-risk patients.