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Zhang C, Amill-Rosario A, Johnson A, Lee H, Spence O, Oraichi D, Seifert H, Franck V, Gamble S, Yun H, dosReis S. Risk of incident gout following exposure to recombinant zoster vaccine in US adults aged ≥50 years. Semin Arthritis Rheum 2024; 68:152515. [PMID: 39047625 DOI: 10.1016/j.semarthrit.2024.152515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/16/2024] [Accepted: 06/10/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE Assess the risk of incident gout following exposure to recombinant zoster vaccine (RZV). METHODS This case-only, self-controlled risk interval study included a cohort of US fee-for-service Medicare (Part A, B, and D) beneficiaries aged ≥65 years. The exposure was receipt of at least one dose of the two-dose RZV regimen in 2018 or 2019. The risk and control windows were days 1-30 and days 31-60, respectively, following vaccination. Incident gout was defined as the first episode of gout during the risk or control window, with no evidence of gout in the last 365 days. We estimated the relative risk (RR) and 95 % confidence interval (CI) of incident gout in the risk window relative to the control window, using conditional Poisson regression models. Sensitivity analyses included a dose-compliant subanalysis of individuals who received dose 2 60-183 days after dose 1; dose-specific analysis; seasonality adjustment; and COVID-19 adjustment for potential detection bias due to the pandemic. RESULTS The 1290 RZV-exposed individuals with incident gout were primarily White (86.98 %), male (61.16 %), and aged 70-79 years (55.82 %). The RR of incident gout was 1.00 (95 % CI 0.90, 1.12). In the dose-compliant sensitivity analysis (n = 959 cases of incident gout), the RR of incident gout was 0.99 (95 % CI 0.87, 1.13). The findings were unchanged in the dose-specific, seasonality, and COVID-19 sensitivity analyses. CONCLUSION The findings suggest that RZV is not significantly associated with an increased risk of incident gout in the Medicare population aged ≥65 years.
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Affiliation(s)
- Chengchen Zhang
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Alejandro Amill-Rosario
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Abree Johnson
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Haeyoung Lee
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | | | | | | | | | | | | - Susan dosReis
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA.
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Källmark H, Bergström T, Nagel J, Gullstrand B, Einarsson JT, Bengtsson AA, Kapetanovic MC. Serologic immunogenicity and safety of herpes zoster subunit vaccine in patients with rheumatoid arthritis receiving Janus kinase inhibitors. Rheumatology (Oxford) 2024; 63:2024-2033. [PMID: 37851412 PMCID: PMC11215978 DOI: 10.1093/rheumatology/kead552] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/12/2023] [Accepted: 09/21/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVE Patients with RA treated with Janus kinase inhibitors (JAKis) are at increased risk of herpes zoster (HZ). The objective of this study was to investigate the serological immunogenicity and safety of the HZ subunit (HZ/su) vaccine in RA patients treated with JAKi, for which little is known. METHODS RA patients treated with JAKi (n = 82) at the Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden, and healthy controls (n = 51) received two doses of the HZ/su vaccine (Shingrix). Vaccine-specific antibody responses were analysed using indirect ELISA. Post-vaccination antibody levels were compared between patients and controls using analysis of covariance. Potential predictors for vaccine response were investigated using a multivariable linear regression analysis. Self-reported adverse events (AEs) and changes in RA disease activity were analysed. RESULTS Following vaccination, vaccine-specific antibody levels increased significantly in both patients and controls (P < 0.0001). A total of 80.5% of patients and 98.0% of controls achieved a ≥4-fold increase in antibody levels. Post-vaccination antibody levels were lower in patients than controls [ratio 0.44 (95% CI 0.31, 0.63)] and lower in patients receiving JAKi + methotrexate than JAKi monotherapy [ratio 0.43 (95% CI 0.24, 0.79)]. AEs, mostly mild/moderate, were common. One patient developed HZ and six patients (6.5%) had increased RA disease activity following vaccination. CONCLUSION The HZ/su vaccine was serologically immunogenic in most RA patients treated with JAKi. Moreover, the vaccine had an acceptable safety profile. These results support recommendations for use of the HZ/su vaccine in this vulnerable population. TRIAL REGISTRATION ClinicalTrials.gov (https://clinicaltrials.gov), NCT03886038.
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Affiliation(s)
- Hanna Källmark
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
| | - Tomas Bergström
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johanna Nagel
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
| | - Birgitta Gullstrand
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
| | - Jon T Einarsson
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
| | - Anders A Bengtsson
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
| | - Meliha C Kapetanovic
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
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Ishihara R, Watanabe R, Shiomi M, Katsushima M, Fukumoto K, Yamada S, Okano T, Hashimoto M. Exploring the Link between Varicella-Zoster Virus, Autoimmune Diseases, and the Role of Recombinant Zoster Vaccine. Biomolecules 2024; 14:739. [PMID: 39062454 PMCID: PMC11274381 DOI: 10.3390/biom14070739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
The varicella-zoster virus (VZV) is a human neurotropic herpes virus responsible for varicella and herpes zoster (HZ). Following primary infection in childhood, VZV manifests as varicella (chickenpox) and enters a period of latency within the dorsal root ganglion. A compromised cellular immune response due to aging or immunosuppression triggers viral reactivation and the development of HZ (shingles). Patients with autoimmune diseases have a higher risk of developing HZ owing to the immunodeficiency associated with the disease itself and/or the use of immunosuppressive agents. The introduction of new immunosuppressive agents with unique mechanisms has expanded the treatment options for autoimmune diseases but has also increased the risk of HZ. Specifically, Janus kinase (JAK) inhibitors and anifrolumab have raised concerns regarding HZ. Despite treatment advances, a substantial number of patients suffer from complications such as postherpetic neuralgia for prolonged periods. The adjuvanted recombinant zoster vaccine (RZV) is considered safe and effective even in immunocompromised patients. The widespread adoption of RZV may reduce the health and socioeconomic burdens of HZ patients. This review covers the link between VZV and autoimmune diseases, assesses the risk of HZ associated with immunosuppressant use, and discusses the benefits and risks of using RZV in patients with autoimmune diseases.
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Affiliation(s)
- Ryuhei Ishihara
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Ryu Watanabe
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Mayu Shiomi
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Masao Katsushima
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Kazuo Fukumoto
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Shinsuke Yamada
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tadashi Okano
- Center for Senile Degenerative Disorders (CSDD), Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Motomu Hashimoto
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
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Park JK, Kim M, Jung JI, Kim JY, Jeong H, Park JW, Winthrop KL, Lee EB. Immunogenicity, reactogenicity, and safety of two-dose adjuvanted herpes zoster subunit vaccine in patients with systemic lupus erythematosus in South Korea: a single-centre, randomised, double-blind, placebo-controlled trial. THE LANCET. RHEUMATOLOGY 2024; 6:e352-e360. [PMID: 38710192 DOI: 10.1016/s2665-9913(24)00084-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/14/2024] [Accepted: 03/19/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND The adjuvanted herpes zoster subunit vaccine has shown good efficacy and safety in the general population. However, its effectiveness has not been comprehensively assessed in patients with systemic lupus erythematosus (SLE). This study aimed to evaluate the immunogenicity and safety of the adjuvanted herpes zoster subunit vaccine in patients with SLE. METHODS This single-centre, randomised, double-blind, placebo-controlled, trial was done at the rheumatology outpatient clinic at Seoul National University Hospital, South Korea. Patients (aged ≥19 years) with clinically stable SLE and previous exposure (≥4 weeks) to immunosuppressive drugs were randomly assigned (4:1) via a central interactive web response system to receive herpes zoster subunit vaccine or placebo (0·5 mL intramuscular injection) at weeks 0 and 8. Investigators and participants were masked to intervention and group assignment. Anti-glycoprotein E antibody titres and glycoprotein E-specific cell-mediated vaccine responses were evaluated at baseline and at week 8 after the first dose, and at week 4, week 26, and week 52 after the second dose using enzyme-linked immunosorbent assay and flow cytometry, respectively. Reactogenicity, SLE disease activity, including Systemic Lupus Erythematosus Disease Activity Index 2000 and British Isles Lupus Assessment Group-flare rate, were examined. The primary outcome was the proportion of patients with a positive humoral vaccine response 4 weeks after the second dose. The primary and safety analyses were done in a modified intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT06001606. FINDINGS Between June 14, and July 19, 2023, 65 patients with SLE were enrolled, of whom 52 were randomly assigned to the herpes zoster subunit vaccine and 13 to placebo. 49 patients in the vaccine group and 11 patients in the placebo group were included in the modified intention-to-treat population. 56 (93%) of 60 patients were women and four (7%) were men. Mean age was 48·7 years (SD 11·4). The proportion of participants with a humoral vaccine response at 4 weeks after the second dose was significantly higher in the vaccine group (48 [98%] of 49 participants) than the placebo group (none [0%] of 11 patients; p<0·0001). More patients in the vaccine group than placebo group reported injection site reactions (42 patients vs two patients), fever (ten vs none), and fatigue (26 vs two). There were no differences in Systemic Lupus Erythematosus Disease Activity Index 2000 and British Isles Lupus Assessment Group-flare rates between the groups. There were no treatment-related deaths. INTERPRETATION The herpes zoster subunit vaccine induces humoral and cellular immunity against herpes zoster with a good safety profile in patients with SLE. A larger study is warranted to assess the efficacy of vaccines to prevent herpes zoster in patients with SLE. FUNDING Ministry of Science and ICT, The Government of the Republic of Korea.
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Affiliation(s)
- Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea; Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Miriam Kim
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea
| | - Ji In Jung
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ju Yeon Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea
| | - Heejin Jeong
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea
| | - Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kevin L Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea; Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea.
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Kostopoulou M, Mukhtyar CB, Bertsias G, Boumpas DT, Fanouriakis A. Management of systemic lupus erythematosus: a systematic literature review informing the 2023 update of the EULAR recommendations. Ann Rheum Dis 2024:ard-2023-225319. [PMID: 38777375 DOI: 10.1136/ard-2023-225319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES To analyse the new evidence (2018-2022) for the management of systemic lupus erythematosus (SLE) to inform the 2023 update of the European League Against Rheumatism (EULAR) recommendations. METHODS Systematic literature reviews were performed in the Medline and the Cochrane Library databases capturing publications from 1 January 2018 through 31 December 2022, according to the EULAR standardised operating procedures. The research questions focused on five different domains, namely the benefit/harm of SLE treatments, the benefits from the attainment of remission/low disease activity, the risk/benefit from treatment tapering/withdrawal, the management of SLE with antiphospholipid syndrome and the safety of immunisations against varicella zoster virus and SARS-CoV2 infection. A Population, Intervention, Comparison and Outcome framework was used to develop search strings for each research topic. RESULTS We identified 439 relevant articles, the majority being observational studies of low or moderate quality. High-quality randomised controlled trials (RCTs) documented the efficacy of the type 1 interferon receptor inhibitor, anifrolumab, in non-renal SLE, and belimumab and voclosporin, a novel calcineurin inhibitor, in lupus nephritis (LN), when compared with standard of care. For the treatment of specific organ manifestations outside LN, a lack of high-quality data was documented. Multiple observational studies confirmed the beneficial effects of attaining clinical remission or low disease activity, reducing the risk for multiple adverse outcomes. Two randomised trials with some concerns regarding risk of bias found higher rates of relapse in patients who discontinued glucocorticoids (GC) or immunosuppressants in SLE and LN, respectively, yet observational cohort studies suggest that treatment withdrawal might be feasible in a subset of patients. CONCLUSION Anifrolumab and belimumab achieve better disease control than standard of care in extrarenal SLE, while combination therapies with belimumab and voclosporin attained higher response rates in high-quality RCTs in LN. Remission and low disease activity are associated with favourable long-term outcomes. In patients achieving these targets, GC and immunosuppressive therapy may gradually be tapered. Cite Now.
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Affiliation(s)
- Myrto Kostopoulou
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - George Bertsias
- Rheumatology and Clinical Immunology, University of Crete, School of Medicine, Heraklion, Greece
- Laboratory of Autoimmunity and Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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Stefanizzi P, Moscara L, Palmieri C, Martinelli A, Di Lorenzo A, Venerito V, Germinario CA, Tafuri S. Safety profile of recombinant adjuvanted anti-herpes zoster vaccine (RZV) in high-risk groups: Data from active surveillance program. Puglia (Italy), 2021-23. Vaccine 2024; 42:2966-2974. [PMID: 38582693 DOI: 10.1016/j.vaccine.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Since 2021 a recombinant adjuvanted anti-Herpes Zoster vaccine(Recombinant Zoster Vaccine, RZV) is offered in Italy to high-risk patients. Few real-life data about RZV safety are available in target populations. OBJECTIVES This study investigates Adverse Events Following Immunization(AEFIs), baseline disease flare-ups, and Herpes Zoster (HZ) episodes occurring after RZV administration in a heterogeneous population of fragile patients to design its safety profile. METHODS This is a retrospective population-based study. RZV-vaccinated patients at Bari Policlinico General Hospital vaccination clinic from October 1st, 2021, to March 31st, 2023, were enrolled. Subjects were screened for reason of RZV eligibility and baseline chronic pathologies. AEFIs occurred in the first 7-days post-vaccination period were collected, and baseline disease flare-ups and post-vaccination HZ episodes were assessed via a 3-month follow-up. RESULTS Five-hundred-thirty-eight patients were included and total of 1,031 doses were administered. Most patients were vaccinated due to ongoing immunosuppressive therapy(54.65 %); onco-hematological and cardiovascular conditions were the most common chronic baseline pathologies. Out of 1,031 follow-ups, 441 AEFI cases were reported(42.7/100). The most common symptoms were injection site pain/itching(35.60/100), asthenia/malaise(11.44/100), and fever (10.09/100). Four serious AEFIs occurred(0.38/100). Older age, male sex, and history of cardiovascular diseases(OR:0.71; 95CI:0.52-0.98; p-value <0.05) were found to decrease AEFIs risk, while endocrine-metabolic illnesses(OR:1.61; 95CI:1.15-2.26; p-value <0.05) increased it. Twelve patients(2.23 %) reported a flare-up/worsening of their baseline chronic condition within the first three months after vaccination(mean interval 31.75 days, range 0-68 days). Patients with rheumatological illnesses had a higher risk of relapse(OR:16.56; 95CI:3.58-76.56; p-value <0.001), while male sex behaved as a protective factor. Twelve patients who completed the vaccination cycle(2.43%) had at least one HZ episode by the long-term follow-up. CONCLUSIONS The study demonstrates RZV safety in a significant number of high-risk patients. Hence, RZV should be actively offered as part of tailored vaccination programs to decrease the burden of HZ in fragile populations.
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Affiliation(s)
- Pasquale Stefanizzi
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy.
| | - Lorenza Moscara
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Claudia Palmieri
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Andrea Martinelli
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Antonio Di Lorenzo
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Vincenzo Venerito
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Cinzia Annatea Germinario
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Silvio Tafuri
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
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Law J, Sorrento C, Saxena A. Vaccination updates and special considerations for systemic lupus erythematosus patients. Curr Opin Rheumatol 2024; 36:148-153. [PMID: 37976046 DOI: 10.1097/bor.0000000000000992] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW We review the latest guidelines and note special considerations for systemic lupus erythematosus (SLE) patients when approaching vaccination against SARS-CoV-2, influenza, pneumococcus, herpes zoster, and potentially respiratory syncytial virus (RSV) vaccine in the future. RECENT FINDINGS SLE patients have unique infectious risks due to newer treatments and the nature of the disease itself. It is important to balance the benefit of additional protective immunity from updated vaccines against the possible risk of disease activity exacerbations. SUMMARY It is important to continuously evaluate the safety and immunogenicity of updated vaccines specifically for SLE patients. Additionally, the newly approved RSV vaccine should be considered for this population to reduce severe respiratory illness.
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Affiliation(s)
- Jammie Law
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
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Kojima S, Iwamoto T, Kobayashi Y, Kato M, Takizawa F, Ida T, Suzuki J, Toda Y, Miyachi K, Iwata A, Furuta S, Ikeda K, Nakajima H. Immunogenicity and influence on disease activity of recombinant zoster vaccine in patients with rheumatoid arthritis treated with DMARDs. RMD Open 2024; 10:e003902. [PMID: 38388170 PMCID: PMC10882334 DOI: 10.1136/rmdopen-2023-003902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/01/2024] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVES This study aimed to determine the immunogenicity and the influence on disease activity of an adjuvanted recombinant varicella-zoster virus (VZV) subunit vaccine (RZV) in patients with rheumatoid arthritis (RA) treated with disease-modifying antirheumatic drugs (DMARDs). METHODS This prospective longitudinal study enrolled 53 patients with RA (aged ≥50 years) treated with DMARDs (conventional synthetic (cs)DMARDs 20, biological (b)DMARDs 23 and targeted synthetic (ts)DMARDs 10) and 10 control individuals. The participants received two intramuscular RZV 2 months apart. VZV-specific CD4+ T cell responses (cell-mediated immunity; CMI) and IgG antibody responses (humoral immunity; HI) were assessed at 0 and 3 months after the first RZV administration using flow cytometry and enzyme immunoassay, respectively. Disease activity (Disease Activity Score 28-C reactive protein and Clinical Disease Activity Index), flares and adverse events were monitored for 6 months after the first vaccination. RESULTS VZV-specific CMI and HI significantly increased in the three DMARDs-treated patients with RA after RZV administration compared with the corresponding prevaccination values (p<0.001-0.014), and the magnitudes and fold-increases of those responses were not significantly different among the three DMARDs-treated patients with RA. Furthermore, the vaccine response rates of CMI and HI were not significantly different between csDMARDs-treated patients and b-DMARDs or ts-DMARDs-treated patients. Meanwhile, no significant increases in disease activity indices or adverse events were observed in these patients during the 6-month follow-up period after the first vaccination. RZV-induced RA flares occurred in two patients (3.8%) but were mild and controllable. CONCLUSION RZV is robustly immunogenic and has a clinically acceptable safety profile in elderly patients with RA receiving DMARDs.
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Affiliation(s)
- Shotaro Kojima
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Taro Iwamoto
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Yoshihisa Kobayashi
- Department of Internal Medicine, Chiba Aoba Municipal Hospital, Chiba, Japan
| | - Manami Kato
- Department of Internal Medicine, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Fumiyoshi Takizawa
- Department of Internal Medicine, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Tomoaki Ida
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Junya Suzuki
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Yosuke Toda
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Kazusa Miyachi
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Arifumi Iwata
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Kei Ikeda
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
- Department of Rheumatology, Dokkyo Medical University, Mibu, Japan
| | - Hiroshi Nakajima
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
- Chiba University Synergy Institute for Futuristic Mucosal Vaccine Research and Development, Chiba, Japan
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9
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Bijl M, Westra J, Mancuso S, Bearzi P, Giacomelli R, Conti F. Should we vaccinate during an active rheumatic disease? Autoimmun Rev 2024; 23:103426. [PMID: 37634680 DOI: 10.1016/j.autrev.2023.103426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
Timing of vaccination and its relationship with concomitant immunosuppressive therapy has been a matter of debate in the field of AutoImmune Inflammatory Rheumatic Diseases (AIIRD). Vaccination is crucial in the prevention of infections, which, in the setting of AIIRD, are known risk factors for disease flare and expose patients to increase risk of complications and mortality. As evidenced from real-life studies, vaccines do not significantly affect disease activity. Conversely, disease activity (especially in Systemic Lupus Erythematosus) may predict for vaccine response: high disease activity correlates with decreased seroconversion. For this reason, according to the EULAR 2019 recommendation, vaccination should preferably be administered during quiescent AIIRD. Beside disease activity, background immunosuppressive therapy should be considered when performing vaccination, as different Disease Modifying Anti-Rheumatic Drugs (DMARDs) decrease vaccine immunogenicity. AIIRD patients should be vaccinated, independently from the vaccine type, before starting immunosuppression. If the patient is on active immunosuppressive therapy, the best window of opportunity to boost vaccine response is during AIIRD quiescence, as low disease activity increases seroconversion and allows safe immunosuppressant spacing. In conclusion, the majority of AIIRD patients should receive vaccination, preferably during quiescent disease and taking into consideration immunosuppressant spacing.
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Affiliation(s)
- Marc Bijl
- Department of Internal Medicine and Rheumatology, Martini Hospital, Groningen, the Netherlands
| | - Johanna Westra
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, the Netherlands
| | - Silvia Mancuso
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari Sapienza University of Rome, Rome, Italy
| | - Pietro Bearzi
- Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy
| | - Roberto Giacomelli
- Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy; Clinical and Research Section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Via Álvaro del Portillo 200, 00128 Rome, Italy.
| | - Fabrizio Conti
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari Sapienza University of Rome, Rome, Italy
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10
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Parikh R, Singer D, Chmielewski-Yee E, Dessart C. Effectiveness and safety of recombinant zoster vaccine: A review of real-world evidence. Hum Vaccin Immunother 2023; 19:2263979. [PMID: 37967254 PMCID: PMC10653743 DOI: 10.1080/21645515.2023.2263979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/23/2023] [Indexed: 11/17/2023] Open
Abstract
The recombinant zoster vaccine (RZV) was licensed in the US for prevention of herpes zoster (HZ) in 2017. We conducted a literature search (January 1, 2017-August 1, 2023) using PubMed, Embase, and Scopus to consolidate the real-world evidence related to RZV. Overall, RZV effectiveness against HZ was high across the studied populations in real-world settings, including adults aged ≥ 50 years and patients aged ≥ 18 years with immunodeficiency or immunosuppression. Effectiveness was higher with two doses versus one dose, especially in elderly people and immunocompromised individuals. The safety profile of RZV was broadly consistent with that established in clinical trials. RZV does not appear to increase the risk of disease flares in patients with immune-mediated diseases. Approximately two-thirds of individuals received a second RZV dose within 2-6 months after the first dose. Collectively, RZV effectiveness against HZ was high, and these real-world studies reaffirm its favorable benefit-risk profile.
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Affiliation(s)
| | - David Singer
- US Health Outcomes and Epidemiology, GSK, Philadelphia, PA, USA
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11
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Alnaimat F, Sweis JJG, Jansz J, Modi Z, Prasad S, AbuHelal A, Vagts C, Hanson HA, Ascoli C, Novak RM, Papanikolaou IC, Rubinstein I, Sweiss N. Vaccination in the Era of Immunosuppression. Vaccines (Basel) 2023; 11:1446. [PMID: 37766123 PMCID: PMC10537746 DOI: 10.3390/vaccines11091446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
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.
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Affiliation(s)
- Fatima Alnaimat
- Department of Internal Medicine, Division of Rheumatology, School of Medicine, University of Jordan, Amman 11942, Jordan
| | | | - Jacqueline Jansz
- Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA; (J.J.); (Z.M.); (S.P.)
| | - Zeel Modi
- Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA; (J.J.); (Z.M.); (S.P.)
| | - Supritha Prasad
- Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA; (J.J.); (Z.M.); (S.P.)
| | | | - Christen Vagts
- Department of Medicine, Division of Pulmonary Critical Care Sleep and Allergy, University of Illinois Chicago, Chicago, IL 60612, USA; (C.V.); (C.A.); (I.R.)
| | - Hali A. Hanson
- College of Pharmacy, University of Illinois Hospital & Health Sciences System, Chicago, IL 60612, USA;
| | - Christian Ascoli
- Department of Medicine, Division of Pulmonary Critical Care Sleep and Allergy, University of Illinois Chicago, Chicago, IL 60612, USA; (C.V.); (C.A.); (I.R.)
| | - Richard M. Novak
- Division of Infectious Diseases, University of Illinois, Chicago, IL 60612, USA;
| | - Ilias C. Papanikolaou
- Department of Respiratory Medicine, Sarcoidosis Clinic, Corfu General Hospital, 49100 Corfu, Greece;
| | - Israel Rubinstein
- Department of Medicine, Division of Pulmonary Critical Care Sleep and Allergy, University of Illinois Chicago, Chicago, IL 60612, USA; (C.V.); (C.A.); (I.R.)
| | - Nadera Sweiss
- Division of Rheumatology, Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA;
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12
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Wroński J, Ciechomska M, Kuca-Warnawin E. Impact of methotrexate treatment on vaccines immunogenicity in adult rheumatological patients - Lessons learned from the COVID-19 pandemic. Biomed Pharmacother 2023; 165:115254. [PMID: 37542854 DOI: 10.1016/j.biopha.2023.115254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023] Open
Abstract
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.
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Affiliation(s)
- Jakub Wroński
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland.
| | - Marzena Ciechomska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland
| | - Ewa Kuca-Warnawin
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland
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13
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Venerito V, Stefanizzi P, Cantarini L, Lavista M, Galeone MG, Di Lorenzo A, Iannone F, Tafuri S, Lopalco G. Immunogenicity and Safety of Adjuvanted Recombinant Zoster Vaccine in Rheumatoid Arthritis Patients on Anti-Cellular Biologic Agents or JAK Inhibitors: A Prospective Observational Study. Int J Mol Sci 2023; 24:ijms24086967. [PMID: 37108130 PMCID: PMC10138868 DOI: 10.3390/ijms24086967] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/06/2023] [Accepted: 04/08/2023] [Indexed: 04/29/2023] Open
Abstract
Rheumatoid arthritis (RA) patients on JAK inhibitors (JAKi) have an increased HZ risk compared to those on biologic DMARDs (bDMARDs). Recently, the Adjuvanted Recombinant Zoster Vaccine (RZV) became available worldwide, showing good effectiveness in patients with inflammatory arthritis. Nevertheless, direct evidence of the immunogenicity of such a vaccine in those on JAKi or anti-cellular bDMARDs is still lacking. This prospective study aimed to assess RZV immunogenicity and safety in RA patients receiving JAKi or anti-cellular bDMARDs that are known to lead to impaired immune response. Patients with classified RA according to ACR/EULAR 2010 criteria on different JAKi or anti-cellular biologics (namely, abatacept and rituximab) followed at the RA clinic of our tertiary center were prospectively observed. Patients received two shots of the RZV. Treatments were not discontinued. At the first and second shots, and one month after the second shot, from all patients with RA, a sample was collected and RZV immunogenicity was assessed and compared between the treatment groups and healthy controls (HCs) receiving RZV for routine vaccination. We also kept track of disease activity at different follow-up times. Fifty-two consecutive RA patients, 44 females (84.61%), with an average age (±SD) of 57.46 ± 11.64 years and mean disease duration of 80.80 ± 73.06 months, underwent complete RZV vaccination between February and June 2022 at our center. At the time of the second shot (1-month follow-up from baseline), anti-VZV IgG titer increased significantly in both groups with similar magnitude (bDMARDs: 2258.76 ± 897.07 mIU/mL; JAKi: 2059.19 ± 876.62 mIU/mL, p < 0.001 for both from baseline). At one-month follow-up from the second shot, anti-VZV IgG titers remained stable in the bDMARDs group (2347.46 ± 975.47) and increased significantly in the JAKi group (2582.65 ± 821.59 mIU/mL, p = 0.03); still, no difference was observed between groups comparing IgG levels at this follow-up time. No RA flare was recorded. No significant difference was shown among treatment groups and HCs. RZV immunogenicity is not impaired in RA patients on JAKi or anti-cellular bDMARDs. A single shot of RZV can lead to an anti-VZV immune response similar to HCs without discontinuing DMARDs.
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Affiliation(s)
- Vincenzo Venerito
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, 70124 Bari, Italy
| | - Pasquale Stefanizzi
- Interdisciplinary Department of Medicine, Aldo Moro University of Bari, 70121 Bari, Italy
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, 53100 Siena, Italy
| | - Marlea Lavista
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, 70124 Bari, Italy
| | - Maria Grazia Galeone
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, 70124 Bari, Italy
| | - Antonio Di Lorenzo
- Interdisciplinary Department of Medicine, Aldo Moro University of Bari, 70121 Bari, Italy
| | - Florenzo Iannone
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, 70124 Bari, Italy
| | - Silvio Tafuri
- Interdisciplinary Department of Medicine, Aldo Moro University of Bari, 70121 Bari, Italy
| | - Giuseppe Lopalco
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, 70124 Bari, Italy
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14
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Bass AR, Chakravarty E, Akl EA, Bingham CO, Calabrese L, Cappelli LC, Johnson SR, Imundo LF, Winthrop KL, Arasaratnam RJ, Baden LR, Berard R, Bridges SL, Cheah JTL, Curtis JR, Ferguson PJ, Hakkarinen I, Onel KB, Schultz G, Sivaraman V, Smith BJ, Sparks JA, Vogel TP, Williams EA, Calabrese C, Cunha JS, Fontanarosa J, Gillispie-Taylor MC, Gkrouzman E, Iyer P, Lakin KS, Legge A, Lo MS, Lockwood MM, Sadun RE, Singh N, Sullivan N, Tam H, Turgunbaev M, Turner AS, Reston J. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol 2023; 75:333-348. [PMID: 36597810 DOI: 10.1002/art.42386] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/31/2022] [Accepted: 10/13/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations on the use of vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs). METHODS This guideline follows American College of Rheumatology (ACR) policy guiding management of conflicts of interest and disclosures and the ACR guideline development process, which includes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It also adheres to the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria. A core leadership team consisting of adult and pediatric rheumatologists and a guideline methodologist drafted clinical population, intervention, comparator, outcomes (PICO) questions. A review team performed a systematic literature review for the PICO questions, graded the quality of evidence, and produced an evidence report. An expert Voting Panel reviewed the evidence and formulated recommendations. The panel included adult and pediatric rheumatology providers, infectious diseases specialists, and patient representatives. Consensus required ≥70% agreement on both the direction and strength of each recommendation. RESULTS This guideline includes expanded indications for some vaccines in patients with RMDs, as well as guidance on whether to hold immunosuppressive medications or delay vaccination to maximize vaccine immunogenicity and efficacy. Safe approaches to the use of live attenuated vaccines in patients taking immunosuppressive medications are also addressed. Most recommendations are conditional and had low quality of supporting evidence. CONCLUSION Application of these recommendations should consider patients' individual risk for vaccine-preventable illness and for disease flares, particularly if immunosuppressive medications are held for vaccination. Shared decision-making with patients is encouraged in clinical settings.
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Affiliation(s)
- Anne R Bass
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Lisa F Imundo
- Columbia University Irving Medical Center, New York, New York
| | | | - Reuben J Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas
| | - Lindsey R Baden
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Roberta Berard
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - S Louis Bridges
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Karen B Onel
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Vidya Sivaraman
- The Ohio State University and Nationwide Children's Hospital, Columbus
| | | | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Joanne S Cunha
- Brown University, Brown Physicians Inc., and Providence Veterans Affairs Medical Center, East Providence, Rhode Island
| | | | | | | | - Priyanka Iyer
- University of California Irvine Medical Center, Orange
| | - Kimberly S Lakin
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Alexandra Legge
- Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Mindy S Lo
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Herman Tam
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
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15
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Bass AR, Chakravarty E, Akl EA, Bingham CO, Calabrese L, Cappelli LC, Johnson SR, Imundo LF, Winthrop KL, Arasaratnam RJ, Baden LR, Berard R, Bridges SL, Cheah JTL, Curtis JR, Ferguson PJ, Hakkarinen I, Onel KB, Schultz G, Sivaraman V, Smith BJ, Sparks JA, Vogel TP, Williams EA, Calabrese C, Cunha JS, Fontanarosa J, Gillispie-Taylor MC, Gkrouzman E, Iyer P, Lakin KS, Legge A, Lo MS, Lockwood MM, Sadun RE, Singh N, Sullivan N, Tam H, Turgunbaev M, Turner AS, Reston J. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Care Res (Hoboken) 2023; 75:449-464. [PMID: 36597813 DOI: 10.1002/acr.25045] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/31/2022] [Accepted: 10/13/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations on the use of vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs). METHODS This guideline follows American College of Rheumatology (ACR) policy guiding management of conflicts of interest and disclosures and the ACR guideline development process, which includes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It also adheres to the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria. A core leadership team consisting of adult and pediatric rheumatologists and a guideline methodologist drafted clinical population, intervention, comparator, outcomes (PICO) questions. A review team performed a systematic literature review for the PICO questions, graded the quality of evidence, and produced an evidence report. An expert Voting Panel reviewed the evidence and formulated recommendations. The panel included adult and pediatric rheumatology providers, infectious diseases specialists, and patient representatives. Consensus required ≥70% agreement on both the direction and strength of each recommendation. RESULTS This guideline includes expanded indications for some vaccines in patients with RMDs, as well as guidance on whether to hold immunosuppressive medications or delay vaccination to maximize vaccine immunogenicity and efficacy. Safe approaches to the use of live attenuated vaccines in patients taking immunosuppressive medications are also addressed. Most recommendations are conditional and had low quality of supporting evidence. CONCLUSION Application of these recommendations should consider patients' individual risk for vaccine-preventable illness and for disease flares, particularly if immunosuppressive medications are held for vaccination. Shared decision-making with patients is encouraged in clinical settings.
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Affiliation(s)
- Anne R Bass
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Lisa F Imundo
- Columbia University Irving Medical Center, New York, New York
| | | | - Reuben J Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas
| | - Lindsey R Baden
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Roberta Berard
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - S Louis Bridges
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Karen B Onel
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Vidya Sivaraman
- The Ohio State University and Nationwide Children's Hospital, Columbus
| | | | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Joanne S Cunha
- Brown University, Brown Physicians Inc., and Providence Veterans Affairs Medical Center, East Providence, Rhode Island
| | | | | | | | - Priyanka Iyer
- University of California Irvine Medical Center, Orange
| | - Kimberly S Lakin
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Alexandra Legge
- Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Mindy S Lo
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Herman Tam
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
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16
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Sullivan KM, Farraye FA, Winthrop KL, Willer DO, Vink P, Tavares-Da-Silva F. Safety and efficacy of recombinant and live herpes zoster vaccines for prevention in at-risk adults with chronic diseases and immunocompromising conditions. Vaccine 2023; 41:36-48. [PMID: 36460534 DOI: 10.1016/j.vaccine.2022.10.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/21/2022] [Accepted: 10/23/2022] [Indexed: 11/30/2022]
Abstract
Compared with the general population, older adults with immune senescence and individuals who are immunocompromised (IC) due to disease or immunosuppressive therapy are at increased risk for herpes zoster (HZ) and its associated complications, which can be debilitating and life-threatening. Vaccination can be an effective strategy against HZ and studies have shown that HZ vaccination in IC individuals can elicit immune responses and provide protection from infection. Recently, the first approvals have been granted in the United States and the European Union for the recombinant HZ vaccine (RZV) in adults ≥ 18 years of age at risk of HZ due to immunodeficiency or immunosuppression. Existing systematic reviews have highlighted the risks for HZ in limited immunocompromising conditions and have only examined clinical data for RZV. This review details the risks and burden of HZ in a broad range of clinically relevant IC populations and summarizes key efficacy and safety data for RZV and live HZ vaccine in these individuals. Research has shown IC individuals can benefit from HZ vaccination; however, these insights have yet to be fully incorporated into vaccination guidelines and clinical care. Clinicians should consider HZ vaccination in eligible at-risk populations to protect against HZ and its associated complications and thereby, reduce the burden that HZ poses on the healthcare system. Electronic health records and linked personal health records could be used to identify and contact patients eligible for HZ vaccination and provide clinical decision support-generated alerts for missing or delayed vaccinations. This review will help clinicians identify eligible IC individuals who may benefit from HZ vaccination. A video abstract linked to this article is available on Figshare https://doi.org/10.6084/m9.figshare.21517605.
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Affiliation(s)
- Keith M Sullivan
- Duke University Medical Center, 200 Trent Dr, Durham, NC 27710, USA.
| | - Francis A Farraye
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Kevin L Winthrop
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, USA.
| | - David O Willer
- GSK Vaccines, 100 Milverton Drive Suite 800, Mississauga, ON, Canada.
| | - Peter Vink
- GSK Vaccines, 14200 Shady Grove Rd, Rockville, MD 20850, USA.
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17
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Leung J, Anderson TC, Dooling K, Xie F, Curtis JR. Recombinant Zoster Vaccine Uptake and Risk of Flares Among Older Adults with Immune-Mediated Inflammatory Diseases in the United States. Arthritis Rheumatol 2022; 74:1833-1841. [PMID: 35666070 DOI: 10.1002/art.42261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/24/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Persons with immune-mediated inflammatory diseases (IMIDs) are at increased risk of herpes zoster (HZ). In 2018, CDC recommended a highly efficacious vaccine, recombinant zoster vaccine (RZV), for prevention of HZ in immunocompetent ≥50 years-olds. We estimated RZV vaccination among adults age ≥50 years with IMIDs during 2018-2019 and examined possible vaccine-related flares following RZV. METHODS We identified a cohort of IMID patients using medical claims data from IBM® MarketScan® (age 50-64 years) and Centers for Medicare and Medicaid Services Medicare (age ≥65 years). Presumed flares were defined as hospitalization/emergency department visit for their respective IMIDs, or steroid treatment with a short-acting oral glucocorticoid or parenteral glucocorticoid injection. We conducted a self-controlled case series (SCCS) analysis to examine a temporal association between RZV and flares. RESULTS Among enrollees with IMIDs, 14.8% of 55,654 MarketScan and 43.2% of 160,545 Medicare enrollees received ≥1-dose of RZV during 2018-2019. Two-dose series completion was 76.6% in MarketScan and 85.4% in Medicare enrollees. In the SCCS analysis, 10% and 13% developed flares in the control as compared to 9% and 11-12% in the risk window following 1- or 2-doses of RZV among MarketScan and Medicare enrollees, respectively. We found no statistically significant increase in flares following RZV administration for any IMID in either age group following RZV dose-1 or dose-2. CONCLUSIONS We did not find an increase in presumed flares following RZV vaccination. Among adults aged ≥50 years with IMIDs, a substantial proportion received RZV compared to general zoster coverage estimates and series-completion was high. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jessica Leung
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Tara C Anderson
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kathleen Dooling
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Fenglong Xie
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
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18
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Maranini B, Ciancio G, Cultrera R, Govoni M. Reply to: "Herpes zoster seven days after SARS-CoV-2 vaccination in a patient with ankylosing spondylitis under adalimumab" by Josef Finsterer. Reumatismo 2022; 74. [PMID: 35506316 DOI: 10.4081/reumatismo.2022.1482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/12/2022] [Indexed: 11/23/2022] Open
Abstract
Not available.
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Affiliation(s)
- B Maranini
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara.
| | - G Ciancio
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara.
| | - R Cultrera
- Infectious Diseases, Department of Translational Medicine, University of Ferrara.
| | - M Govoni
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara.
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19
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Nakamura Y, Honda D, Takizawa N, Fujita Y. Herpes zoster meningitis in a rheumatoid arthritis patient treated with tofacitinib. BMJ Case Rep 2022; 15:e247276. [PMID: 35236687 PMCID: PMC8895891 DOI: 10.1136/bcr-2021-247276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 12/30/2022] Open
Abstract
A man in his 70s with rheumatoid arthritis presented with seizures and coma and was transferred to our emergency department. Two months prior to admission, he started to take tofacitinib 10 mg/day. On admission, we noted a rash with a blister on the forehead, and herpes zoster was diagnosed. Cerebrospinal fluid examination suggested meningitis. An MRI of the brain showed no abnormality. Based on these findings, he was suspected with herpes zoster meningitis. We discontinued tofacitinib and treated the patient with intravenous acyclovir for 2 weeks. He regained complete consciousness, but right forehead skin lesion, severe vision loss in the right eye and right facial nerve paralysis remained as sequelae. Six weeks after admission, we restarted tofacitinib with oral valaciclovir as antiviral prophylaxis. Two years after admission, we administered Shingrix, an adjuvant recombinant vaccine for herpes zoster, and discontinued oral valaciclovir.
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Affiliation(s)
| | - Daiyu Honda
- Department of Neurology, Nagoya Daiichi Sekijuji Byoin, Nagoya, Aichi, Japan
| | - Naoho Takizawa
- Department of Rheumatology, Chubu Rosai Hospital, Nagoya, Aichi, Japan
| | - Yoshiro Fujita
- Department of Rheumatology, Chubu Rosai Hospital, Nagoya, Aichi, Japan
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20
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Raza S, Acharya S, Howard G, Pattanaik D. Safety of Recombinant Zoster Vaccine in Rheumatology Patients. South Med J 2022; 115:125-128. [PMID: 35118501 DOI: 10.14423/smj.0000000000001354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Recombinant zoster vaccine (RZV) is Food and Drug Administration approved for the prevention of herpes zoster (shingles) in adults 50 years old and older. Immunocompromised subjects were excluded from the pivotal vaccine trials. We studied the safety of this vaccine in our university-affiliated rheumatology practice. METHODS This was a single-center, retrospective study focusing on subjects who received RZV during 2018. We collected the demographic data, any self-reported adverse events after vaccination, C-reactive protein, Routine Assessment of Patient Index Data 3 (RAPID3) scores for subjects with rheumatoid arthritis, and available RAPID3 scores for all study subjects before and after the vaccination. RESULTS Comparision of C-reactive protein (n = 40), RAPID3 scores for subjects with rheumatoid arthritis (n = 16), and available RAPID3 scores for all subjects (n = 21) using the paired t test, did not show significant differences before and after the administration of RZV. A total of 6.4% of patients reported adverse events after vaccination. The adverse events were mild and did not lead to hospitalization, end organ damage, or change in treatment plan. CONCLUSIONS The RZV was safe and well tolerated among our study population.
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Affiliation(s)
- Syed Raza
- From the Departments of Rheumatology and Internal Medicine, University of Tennessee Health Science Center, Memphis
| | - Saurav Acharya
- From the Departments of Rheumatology and Internal Medicine, University of Tennessee Health Science Center, Memphis
| | - Gabrielle Howard
- From the Departments of Rheumatology and Internal Medicine, University of Tennessee Health Science Center, Memphis
| | - Debendra Pattanaik
- From the Departments of Rheumatology and Internal Medicine, University of Tennessee Health Science Center, Memphis
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21
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Liu C, Kieltyka J, Fleischmann R, Gadina M, O’Shea JJ. A Decade of JAK Inhibitors: What Have We Learned and What May Be the Future? Arthritis Rheumatol 2021; 73:2166-2178. [PMID: 34180156 PMCID: PMC8671145 DOI: 10.1002/art.41906] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/23/2021] [Indexed: 12/15/2022]
Abstract
The discovery of cytokines and their role in immune and inflammatory disease led to the development of a plethora of targeted biologic therapies. Later, efforts to understand mechanisms of cytokine signal transduction led to the discovery of JAKs, which themselves were quickly identified as therapeutic targets. It has been a decade since the first JAK inhibitors (jakinibs) were approved, and there are now 9 jakinibs approved for the treatment of rheumatic, dermatologic, hematologic, and gastrointestinal indications, along with emergency authorization for COVID-19. In this review, we will summarize relevant discoveries that led to first-generation jakinibs and review their efficacy and safety as demonstrated in pivotal clinical studies. We will discuss the next generation of more selective jakinibs, along with agents that target kinase families beyond JAKs. Finally, we will reflect on both the opportunities and challenges ahead as we enter the second decade of the clinical use of jakinibs.
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Affiliation(s)
- Christine Liu
- Translational Immunology Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jacqueline Kieltyka
- Translational Immunology Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Roy Fleischmann
- Metroplex Clinical Research Center, University of Texas Southwestern Medical Center
| | - Massimo Gadina
- Translational Immunology Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John J. O’Shea
- Molecular Immunology and Inflammation Branch. National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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22
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Friedman MA, Curtis JR, Winthrop KL. Impact of disease-modifying antirheumatic drugs on vaccine immunogenicity in patients with inflammatory rheumatic and musculoskeletal diseases. Ann Rheum Dis 2021; 80:1255-1265. [PMID: 34493491 DOI: 10.1136/annrheumdis-2021-221244] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/25/2021] [Indexed: 12/14/2022]
Abstract
Patients with rheumatic diseases are at increased risk of infectious complications; vaccinations are a critical component of their care. Disease-modifying antirheumatic drugs may reduce the immunogenicity of common vaccines. We will review here available data regarding the effect of these medications on influenza, pneumococcal, herpes zoster, SARS-CoV-2, hepatitis B, human papilloma virus and yellow fever vaccines. Rituximab has the most substantial impact on vaccine immunogenicity, which is most profound when vaccinations are given at shorter intervals after rituximab dosing. Methotrexate has less substantial effect but appears to adversely impact most vaccine immunogenicity. Abatacept likely decrease vaccine immunogenicity, although these studies are limited by the lack of adequate control groups. Janus kinase and tumour necrosis factor inhibitors decrease absolute antibody titres for many vaccines, but do not seem to significantly impact the proportions of patients achieving seroprotection. Other biologics (interleukin-6R (IL-6R), IL-12/IL-23 and IL-17 inhibitors) have little observed impact on vaccine immunogenicity. Data regarding the effect of these medications on the SARS-CoV-2 vaccine immunogenicity are just now emerging, and early glimpses appear similar to our experience with other vaccines. In this review, we summarise the most recent data regarding vaccine response and efficacy in this setting, particularly in light of current vaccination recommendations for immunocompromised patients.
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Affiliation(s)
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham Department of Medicine, Birmingham, Alabama, USA
| | - Kevin L Winthrop
- Medicine, Oregon Health & Science University, Portland, Oregon, USA.,School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
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