An extra priming dose of hepatitis A vaccine to adult patients with rheumatoid arthritis and drug induced immunosuppression - A prospective, open-label, multi-center study

Impact of methotrexate treatment on vaccines immunogenicity in adult rheumatological patients - Lessons learned from the COVID-19 pandemic

Despite the development of new biological and synthetic targeted therapies, methotrexate remains one of the most commonly used immunomodulatory drugs in rheumatology. However, its effect on the immunogenicity of vaccines has been studied only to a limited extent until recently, resulting in the lack of clear guidelines on the use of methotrexate during vaccination. Significant progress was made during the COVID-19 pandemic due to the dynamic development of research on vaccines, including patients with autoimmune inflammatory rheumatic diseases. In the following literature review, we present a summary of what we know so far on the impact of methotrexate on post-vaccination response in adult rheumatology patients, taking into account the lessons learned from the COVID-19 pandemic. Studies on the effect of methotrexate on the immunogenicity of influenza, pneumococcal, herpes zoster, tetanus/diphtheria/pertussis, hepatitis A, yellow fever, and COVID-19 vaccines are described in detail, including the effect of methotrexate on the humoral and cellular response of individual vaccines. The available evidence for recommendations for withholding methotrexate in the post-vaccination period is presented. Lastly, an overview of potential immunological mechanisms through which MTX modulates the immunogenicity of vaccinations is also provided.

Polyfunctional antibodies: a path towards precision vaccines for vulnerable populations

Vaccine efficacy determined within the controlled environment of a clinical trial is usually substantially greater than real-world vaccine effectiveness. Typically, this results from reduced protection of immunologically vulnerable populations, such as children, elderly individuals and people with chronic comorbidities. Consequently, these high-risk groups are frequently recommended tailored immunisation schedules to boost responses. In addition, diverse groups of healthy adults may also be variably protected by the same vaccine regimen. Current population-based vaccination strategies that consider basic clinical parameters offer a glimpse into what may be achievable if more nuanced aspects of the immune response are considered in vaccine design. To date, vaccine development has been largely empirical. However, next-generation approaches require more rational strategies. We foresee a generation of precision vaccines that consider the mechanistic basis of vaccine response variations associated with both immunogenetic and baseline health differences. Recent efforts have highlighted the importance of balanced and diverse extra-neutralising antibody functions for vaccine-induced protection. However, in immunologically vulnerable populations, significant modulation of polyfunctional antibody responses that mediate both neutralisation and effector functions has been observed. Here, we review the current understanding of key genetic and inflammatory modulators of antibody polyfunctionality that affect vaccination outcomes and consider how this knowledge may be harnessed to tailor vaccine design for improved public health.

ImmunoStart: preparing patients for immunosuppression

Objectives

Patients with immune-mediated inflammatory disease (IMID) present an increased risk of infection. Here, we present the concept of a preventive consultation called ImmunoStart and the first results of its implementation in the care pathway of patients with IMID.

Methods

Relevant information about vaccination history, tuberculosis exposure and other infectious risks were collected through blood sampling, complete anamnesis, chest X-ray and Mantoux test. During the ImmunoStart consultation, vaccination schedules, specific treatments and risk considerations were discussed.

Results

Between October 2016 and February 2020, 437 patients were seen at an ImmunoStart consultation, mainly referred by rheumatologists (56%), dermatologists (25%) and gastroenterologists (18%). A total of 421 (96%) patients needed at least one vaccine (a mean of 3.3 vaccines per patient). Live attenuated vaccine was indicated for 45 patients (10%), requiring them to reduce or interrupt their immunosuppressive drug(s). Ninety-two patients (21%) were treated for latent tuberculosis infection.

Conclusion

This preventive consultation provides a centralized and systematic setting for the direct management of patients with IMID in need of vaccination, treatment of latent disease and specific advice regarding their immunomodulating treatments.

[Travelling with children and adolescents with rheumatic diseases]

Due to the underlying disease and immunosuppressive treatment, pediatric patients with rheumatic diseases are at increased risk for (long distance) travel-related health problems. A pretravel comprehensive consultation is therefore strongly recommended. Whether a child with rheumatic disease is sufficiently fit for travel essentially depends on the disease activity, the age of the child and the intended travel destination. Depending on the level of immunosuppression, the risks for this patient group include (travel-related) infections and the possibility of disease activity flares. Of particular importance is adequate exposure prevention: standard vaccinations should be updated and indications for travel vaccinations evaluated in advance of travelling. In this context, potential contraindications, especially for live vaccines, in the case of specific immunosuppressive treatment should be considered. In the event of travel to malaria endemic areas, the necessity for chemoprophylaxis or stand-by medication must be evaluated but caution is needed regarding potential drug interactions. Detailed education about careful hand, food and contact hygiene is critical. Because photosensitivity may be increased in some rheumatic diseases and/or medications, UV protection is crucial. Barriers (clothes and mosquito nets) and age-appropriate chemical insect repellents should be used to prevent insect-borne diseases. Before start of travel, possibilities for on-site medical help in the event of disease deterioration and/or infection should be evaluated. This should be included in the assessment of the patient's ability to travel. Travelers with rheumatic disease should carry a first aid kit that includes both a sufficient supply of regular antirheumatic medication and supplemental medication in case of a disease flare. Storage conditions must be taken ínto account for some medications. Ultimately, the success of a journey depends on the planning from the perspective of the child with its specific needs.

An evidence-based guide to SARS-CoV-2 vaccination of patients on immunotherapies in dermatology

Immune-mediated diseases and immunotherapeutics can negatively affect normal immune functioning and, consequently, vaccine safety and response. The COVID-19 pandemic has incited research aimed at developing a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. As SARS-CoV-2 vaccines are developed and made available, the assessment of anticipated safety and efficacy in patients with immune-mediated dermatologic diseases and requiring immunosuppressive and/or immunomodulatory therapy is particularly important. A review of the literature was conducted by a multidisciplinary committee to provide guidance on the safety and efficacy of SARS-CoV-2 vaccination for dermatologists and other clinicians when prescribing immunotherapeutics. The vaccine platforms being used to develop SARS-CoV-2 vaccines are expected to be safe and potentially effective for dermatology patients on immunotherapeutics. Current guidelines for the vaccination of an immunocompromised host remain appropriate when considering future administration of SARS-CoV-2 vaccines.

[Travel vaccinations in rheumatic diseases : Specific considerations in children and adults]

Children and adults with rheumatic diseases (RD) have a higher risk to contract infections due to the underlying disease and the frequently necessary immunosuppressive treatment (IT). The quality of life of the majority of patients with RD has remarkably improved due to IT-related reduction of inflammation. Therefore, RD patients usually have an international travel behavior similar to healthy individuals. An investigation indicated that patients with RD and IT have lower travel vaccination rates and are often less well-prepared for their trip in comparison to healthy travelers, even when visiting high risk destinations. As the risk for general and travel-acquired infections is increased for patients with RD with and without IT, pretravel consultations are important. These pretravel consultations should include recommendations addressing travel cancellation, travel modification and travel vaccinations depending on the patient's risk. Travel vaccinations include vaccinations against hepatitis A, typhoid fever, rabies, cholera, meningococcal diseases, tick-bone encephalitis, Japanese encephalitis, seasonal influenza, poliomyelitis and yellow fever. In patients with RD the indications for vaccination depend on the exposure risks, disease severity, individual travel behavior, and possible complications associated with vaccination. In the further evaluation process it is crucial to include the general health condition of the patient, the underlying RD (type and activity), duration and intensity of the IT. In general, live-attenuated vaccines are contraindicated under IT. In contrast, inactivated vaccines may be administered although reduced immunogenicity with the need for antibody measurement, special vaccine schedules or additional booster vaccinations should be considered under IT.

[Most important vaccinations in patients with rheumatological diseases and why]

Lange Zeit schienen die meisten Infektionen beherrschbar geworden zu sein. Hierzu haben besonders auch Impfungen beigetragen. In den letzten Jahren gefährden neu aufgetretene bakterielle Infektionen durch multiresistente Erreger und Virusinfektionen wie das Chikungunya-Virus, Influenzaepidemien oder aktuell auch COVID-19 die Weltbevölkerung. Dies gilt in besonderer Weise für von rheumatologischen Erkrankungen Betroffene, die oft zusätzlich einer immunsuppressiven Therapie bedürfen und damit besonders durch Infektionen gefährdet sind. Impfungen können die Betroffenen sowohl individuell wie auch durch die Erzeugung einer Herdenimmunität schützen und stellen somit ein wichtiges Instrument dar, um die Morbidität und Mortalität durch Infektionen zu vermindern. Die Kenntnis über Indikation und Anwendung der einzelnen Impfungen ist für eine konsequente Umsetzung der aktuellen Empfehlungen besonders wichtig.

Travel patterns, risk behaviour and health problems of travellers with rheumatic diseases compared to controls: A multi-centre, observational study

BACKGROUND

Patients with chronic conditions travel around the world more than ever. Only few studies have examined travel patterns and health outcomes of patients with rheumatic diseases during international travel.

METHOD

We conducted a multi-centre prospective cohort study in Switzerland, in which we studied the immunogenicity and safety of vaccinations in patients with rheumatic diseases and travellers without rheumatic diseases (controls). Participants who travelled internationally received questionnaires 1 and 13 weeks post-travel. We compared travel patterns, risk behaviours, and travel-associated problems during and after the trips in both groups.

RESULTS

274 participants returned post-travel questionnaires (65 rheumatic patients, 209 controls). Controls more frequently travelled to subtropical/tropical destinations and stayed longer abroad. 64% of all participants experienced health problems during travel (74% rheumatic patients vs. 62% controls, P = 0.11). Pre-travel, patients reported a higher susceptibility to gastrointestinal infections . During travel, a higher percentage of rheumatic patients cancelled the day programme due to health problems (13% vs. 4%, P = 0.024). The main problems in rheumatic patients occurred due to the underlying rheumatic diseases, or were of psychological nature. Although not statistically significant, infectious disease symptoms (rhinitis, cough) occurred more frequently in controls. When only considering subtropical/tropical destinations, rheumatic patients more frequently had gastrointestinal problems during travel - and skin infections after the trip.

CONCLUSIONS

This study does not support the notion that patients with rheumatic diseases should avoid international travel for an increased risk of infections. In patients with subtropical/tropical destinations, however, gastrointestinal problems may be increased during travel - and skin infections post-travel.

Hepatitis A vaccination

Hepatitis A is an important public health issue worldwide. Hepatitis A vaccine (HepA) was first licensed in 1992. Both inactivated HepA (HepA-I) and live attenuated HepA (HepA-L) are highly immunogenic and well tolerated, and immune protection postvaccination can persist for at least 20 y. HepA is effective for both preexposure and postexposure prophylaxis, especially among children and young adults. The strategy of HepA vaccination varies in different countries and mainly includes vaccination among high-risk populations, regional childhood vaccination and universal childhood vaccination. The incidence of hepatitis A has decreased greatly in many countries in the last 30 y, but hepatitis A outbreaks frequently occur among high-risk populations and those who have not been covered by universal child vaccination programs in recent years. Disease surveillance and serosurveys are suggested to clarify the shift in the epidemiology of hepatitis A. The long-term persistence of immune protection after one dose of HepA should be further studied, as well as the cost-effective evaluation of different strategies of HepA vaccination. Based on this evidence, the recommendation on HepA vaccination should be put forward scientifically and updated in a timely and well-implemented manner.

[Travel vaccinations for certain groups of persons]

The number of international travelers has been continuously increasing in recent decades. Among travelers, there are more and more people at an increased risk for acquiring diseases that could be prevented by vaccines or for the development of a severe course of disease. Risk groups in travel medicine are senior travelers, children, pregnant and breast-feeding women, persons with pre-existing medical conditions, and persons who visit their friends and relatives abroad (VFR). Individuals in these groups require attention during pretravel advice consultations, particularly with regards to recommended vaccinations. On the other hand, for some risk groups, particular vaccines cannot be given for safety reasons or because the response to vaccines is reduced. Not all risk groups or each vaccine have sufficient evidence available, so each patient's risks and benefits must be weighed during pretravel consultation. In this article, the particularities for each risk group with respect to pretravel immunization are highlighted.

Vaccines for International Travel

The pretravel management of the international traveler should be based on risk management principles. Prevention strategies and medical interventions should be based on the itinerary, preexisting health factors, and behaviors that are unique to the traveler. A structured approach to the patient interaction provides a general framework for an efficient consultation. Vaccine-preventable diseases play an important role in travel-related illnesses, and their impact is not restricted to exotic diseases in developing countries. Therefore, an immunization encounter before travel is an ideal time to update all age-appropriate immunizations as well as providing protection against diseases that pose additional risk to travelers that may be delineated by their destinations or activities. This review focuses on indications for each travel-related vaccine together with a structured synthesis and graphics that show the geographic distribution of major travel-related diseases and highlight particularly high-risk destinations and behaviors. Dosing, route of administration, need for boosters, and possible accelerated regimens for vaccines administered prior to travel are presented. Different underlying illnesses and medications produce different levels of immunocompromise, and there is much unknown in this discipline. Recommendations regarding vaccination of immunocompromised travelers have less of an evidence base than for other categories of travelers. The review presents a structured synthesis of issues pertinent to considerations for 5 special populations of traveler: child traveler, pregnant traveler, severely immunocompromised traveler, HIV-infected traveler, and traveler with other chronic underlying disease including asplenia, diabetes, and chronic liver disease.

Hepatitis A vaccine immunogenicity in patients using immunosuppressive drugs: A systematic review and meta-analysis

INTRODUCTION

Inactivated hepatitis A (HepA) vaccines are very immunogenic in healthy individuals; however, it remains unclear how different immunosuppressive regimens affect HepA vaccine immunogenicity. Our objective was to summarise the current evidence on immunogenicity of HepA vaccination in patients using immunosuppressive drugs.

METHODS

We systematically searched the literature for studies on immunogenicity of inactivated HepA vaccines in adults using immunosuppressive drugs. Studies reporting seroconversion rates (SCR) 4-8 weeks after 1 and 2 doses of HepA vaccine in organ transplant recipients and patients with chronic inflammatory conditions were included in a meta-analysis.

RESULTS

We included 17 studies, comprising 1,332 individuals. In healthy controls (2 studies), SCRs were 90-94% after the first dose and 100% after the second dose. In organ transplant recipients, SCRs ranged from 0 to 67% after the first dose of vaccine and 0-97% after the second dose. In patients with chronic inflammatory conditions, SCRs ranged from 6% to 100% after the first dose and from 48 to 100% after the second dose of vaccine. Patients using a TNF-alpha inhibitor versus conventional immune-modulators (e.g. methotrexate, azathioprine, corticosteroids) were more likely to seroconvert after the first dose of vaccine (OR12.1 [2.14-68.2]) but not after the second dose of vaccine (OR 0.78 [0.21-2.92]) in a meta-analysis.

CONCLUSION

Studies evaluating HepA vaccine immunogenicity in immunosuppressive agents are heterogeneous. Overall, there is an impaired immune response following HepA vaccination in patients using immunosuppressive drugs, especially after only one dose of vaccine and in organ transplant recipients. HepA vaccination should therefore be considered before immunosuppressive therapy. Future research should focus on alternative vaccination regimens and long-term immunogenicity.

PROSPERO ID

CRD42018102607.

Efficacy, immunogenicity and safety of vaccination in adult patients with autoimmune inflammatory rheumatic diseases: a systematic literature review for the 2019 update of EULAR recommendations

Aim

To present a systematic literature review (SLR) on efficacy, immunogenicity and safety of vaccination in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD), aiming to provide a basis for updating the EULAR evidence-based recommendations.

Methods

An SLR was performed according to the standard operating procedures for EULAR-endorsed recommendations. Outcome was determined by efficacy, immunogenicity and safety of vaccination in adult patients with AIIRD, including those receiving immunomodulating therapy. Furthermore, a search was performed on the effect of vaccinating household members of patients with AIIRD on the occurrence of vaccine-preventable infections in patients and their household members (including newborns). The literature search was performed using Medline, Embase and the Cochrane Library (October 2009 to August 2018).

Results

While most investigated vaccines were efficacious and/or immunogenic in patients with AIIRD, some were less efficacious than in healthy control subjects, and/or in patients receiving immunosuppressive agents. Adverse events of vaccination were generally mild and the rates were comparable to those in healthy persons. Vaccination did not seem to lead to an increase in activity of the underlying AIIRD, but insufficient power of most studies precluded arriving at definite conclusions. The number of studies investigating clinical efficacy of vaccination is still limited. No studies on the effect of vaccinating household members of patients with AIIRD were retrieved.

Conclusion

Evidence on efficacy, immunogenicity and safety of vaccination in patients with AIIRD was systematically reviewed to provide a basis for updated recommendations.

Hepatitis A in Switzerland: An analysis of 29 years of surveillance data and contemporary challenges

BACKGROUND

Hepatitis A (HA) incidence declined in most European countries in the past decades. We analysed HA notification data for Switzerland of 29 years looking for disease- and notification system-related factors possibly contributing to observed trends.

METHOD

Notification data were descriptively analysed using five time intervals (1988-1993, 1994-1999, 2000-2005, 2006-2011, 2012-2016); and notification rates were calculated.

RESULTS

From 1988 to 2016, the HA notification rate decreased from 9.5 to 0.5 per 100'000 population in Switzerland. Median age and the proportion of hospitalised cases increased over time. In the 1988-1993-time period, intravenous drug use was the most frequently mentioned risk exposure while consumption of contaminated food/beverages was most frequently mentioned in the 2012-2016-time period.

CONCLUSIONS

Notification data does not allow reliably identifying current risk groups (e.g. travellers) due to low case numbers, limited availability and reliability of information. It is important to document changes in the surveillance system for later analyses and interpretation of long-term trends. Population susceptibility likely increases underlining the importance of continued and continuous surveillance and prevention efforts despite decreasing case numbers. Operational research is recommended to further investigate observed trends of HA and to enhance the abilities for decision making from Swiss HA surveillance data.

Travel-related health problems in the immunocompromised traveller: An exploratory study

BACKGROUND

Immunocompromised travellers (ICTs) are at increased risk of travel-related health problems. Therefore, they are advised to attend specialised pre-travel clinics for advice on vaccination, malaria chemoprophylaxis and on-demand antibiotics. However, studies yield conflicting data regarding travel-related health problems encountered by ICTs; questioning the rationale for certain advices, and particularly the advice of on-demand antibiotics.

OBJECTIVE

To evaluate self-reported travel-related health problems, antibiotic use, medical visits and risk behaviours in ICTs and controls.

METHODS

We conducted a questionnaire-based observational study with pilot character. We recruited participants from a (medical) pre-travel clinic. Telephone interviews were conducted 2-4 weeks post-travelling, applying a structured questionnaire.

RESULTS

We included 30 ICTs and 30 controls. More ICTs than controls reported travel-related health problems, antibiotic use and medical visits, although not statistically significant. Travellers' diarrhoea appeared to be more severe in ICTs. Furthermore one ICT was hospitalized post-travel due to pneumonia. Of ICTs, 2/30 (7%) used on demand antibiotics while not indicated (according to the protocol of the Dutch national coordinating centre for travel advice or prescribed by a physician). Reversely, 6/30 (20%) did not use on demand antibiotics while actually indicated according to this protocol.

DISCUSSION

Our findings substantiate the recommendation of on demand antibiotics. However, ICTs did often not use on demand antibiotics correctly; they therefore need very careful instructions.