Vaccinate your immunocompromised patients!

Human Papillomavirus, Herpes Zoster, and Hepatitis B Vaccinations in Immunocompromised Patients: An Update for Pharmacists

PURPOSE

Current evidence regarding efficacy and safety of human papillomavirus 9-valent (9vHPV), recombinant zoster (RZV), and CpG-adjuvanted recombinant hepatitis B (HepB-CpG) vaccines in adults with human immunodeficiency virus, inflammatory bowel disease, solid organ transplant, and allogeneic hematopoietic stem cell transplant is reviewed.

SUMMARY

Patients immunocompromised due to underlying disease or treatment are at increased risk for infections; however, insufficient understanding of various vaccines' efficacy, safety, indications, and contraindications in this population has led to suboptimal vaccination rates. The Infectious Disease Society of America (IDSA) published guidelines on vaccines in immunocompromised populations in 2013. Since then, several advances have been made including an expanded indication with 9vHPV for use in males and females 9 to 45 years old, and the introduction of new vaccines for herpes zoster (RZV) and hepatitis B (HepB-CpG). Pharmacists are instrumental to vaccination efforts and may benefit from a review of recent vaccine updates.

CONCLUSION

The 9vHPV can be used in men and women ages 9 to 45 years old regardless of immune status. RZV safety and efficacy in several immunocompromised populations has been demonstrated; however, manufacturers and major societies have yet to update their recommendations. HepB-CpG may be used in most immunocompromised patients yet remains under-utilized.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Antibody responses to influenza vaccine in patients on biological therapy: Results of RIER cohort study

BACKGROUND AND OBJECTIVES

Influenza vaccine is recommended for patients with autoimmune inflammatory rheumatic diseases who receive biological therapy. To evaluate if biological therapy impairs immunization after seasonal influenza vaccine.

MATERIAL AND METHODS

Patients with inflammatory arthopathies, psoriasis, inflammatory bowel disease or connective tissue diseases who were receiving or were going to initiate biological therapy were included and vaccinated during 2014-2015 influenza season. ELISA was used to measure influenza antigen A and B antibodies, before and after vaccination. Demographic parameters, diagnosis and kind of treatment were recorded and their influence on the final serological status against influenza was studied.

RESULTS

253 subjects were analyzed. After vaccination, 77% of participants presented detectable antibodies against antigen A and 50.6% of them had detectable antibodies against antigen B. Final seropositivity rate against antigen B antibodies increased from baseline (50.6% vs 43.5%, p<0.001). Anti-TNF drugs were associated with better response and rituximab with the worst (79.2% vs 55.0% for final seropositivity against antigen A, p=0.020). Vaccine response in the rituximab group tended to improve when the interval between the drug administration and the vaccination was at least 12 weeks (seropositivity rate 80.0% in those with the longer interval vs 25.0% in the other group, p=0.054).

CONCLUSIONS

Among the patients on biological therapy vaccinated against influenza, anti-TNF therapy was identified as a predictive factor of final seropositivity. Rituximab presented a lower rate of final seropositivity, which could be increased with an accurate administration schedule.

Vaccination practices in patients with inflammatory bowel disease among general internal medicine physicians in the USA

BACKGROUND

Increasing prevalence of inflammatory bowel disease (IBD) poses significant challenges to medical community. Preventive medicine, including vaccination against opportunistic infections, is important in decreasing morbidity and mortality in patients with IBD. We conduct first study to evaluate general awareness and adherence to immunisation guidelines by primary care physicians in the USA.

METHODS

We administered an electronic questionnaire to the research panel of the American College of Physicians (ACP) assessing current vaccination practices, barriers to vaccination and provider responsibility for administering vaccinations and compared responses with the European Crohn's and Colitis Organization consensus guidelines and expert opinion from the USA.

RESULTS

All of surveyed physicians (276) had experience with patients with IBD and spent majority of their time in direct patient care. 49% of physicians took immunisation history frequently or always, and 76% reported never or rarely checking immunisation antibody titres with only 2% doing so routinely. 65% of physicians believed that primary care providers (PCPs) were responsible for determining patient's immunisation. Vaccine administration was felt to be the duty of primary care doctor 80% of the time. 2.5% of physicians correctly recommended vaccinations all the time. Physicians were more likely to recommend vaccination to immunocompetent than immunocompromised patients. Up to 23% of physicians would incorrectly recommend live vaccine to immunocompromised patients with IBD.

CONCLUSIONS

Current knowledge and degree of comfort among PCPs in the USA in preventing opportunistic infections in IBD population remain low. Management of patients with IBD requires structured approach to their healthcare maintenance in everyday practice, including enhanced educational policy aimed at primary care physicians.

Low rate of influenza and pneumococcal vaccine coverage in rheumatoid arthritis: data from the international COMORA cohort

BACKGROUND

Rheumatoid Arthritis (RA) patients are at increased risk of suffering from respiratory infections than the general public. Vaccinations against Streptococcus pneumococcus and influenza are recommended, but not often used in RA. Our objectives were: (1) to describe pneumococcal and influenza vaccine coverage in RA patients across various countries and (2) to identify factors associated with their usage.

METHODS

Using data from the COMORA cohort, 3920 RA patients were enrolled across 17 countries. We collected patient demographic and disease characteristics, and reported vaccine use over a six month time period. We used logistic regression to evaluate factors related to pneumococcal and influenza vaccine coverage.

RESULTS

Overall vaccination coverage within the recommendations was low with huge disparities between countries: 17.2% (95%CI: 16.0-18.4) for pneumococcal vaccination (from 0% in Morocco to 56.5% in France) and 25.3% (95%CI: 23.8-26.5) for influenza vaccination (less than 1% in Morocco and Egypt to 66.2% in Japan). In countries where immunization was more frequent, we found that predictive factors of vaccination were older age, lower disease activity, higher educational level, use of biotherapy, absence of corticosteroid therapy, and presence of comorbidities.

CONCLUSION

Despite international recommendations for influenza and pneumococcal vaccination, we observed a low prevalence of these vaccinations among RA patients, with huge disparity between countries. Efforts are needed to better inform patients and physicians regarding the need for vaccinations.

Effect of methotrexate, anti-tumor necrosis factor α, and rituximab on the immune response to influenza and pneumococcal vaccines in patients with rheumatoid arthritis: a systematic review and meta-analysis

OBJECTIVE

To assess the current literature on the impact of rheumatoid arthritis (RA) treatments on the humoral response to pneumococcal and influenza vaccines.

METHODS

We systematically searched the literature for studies evaluating the immune response to vaccines in RA patients receiving methotrexate (MTX) and/or biologic agents. The efficacy of vaccination, assessed by the response rate based on increased antibody titers before and 3-6 weeks after vaccination, was extracted by one investigator and verified by another.

RESULTS

In total, 12 studies were included. RA patients mainly received MTX, anti-tumor necrosis factor α (anti-TNFα), or rituximab (RTX). Influenza vaccination response was reduced for RTX (43 patients; pooled odds ratio [OR] 0.44 [95% confidence interval (95% CI) 0.17-1.12] for H1N1, OR 0.11 [95% CI 0.04-0.31] for H3N2, and OR 0.29 [95% CI 0.10-0.81] for B) but not for anti-TNFα (308 patients; OR 0.93 [95% CI 0.36-2.37] for H1N1, OR 0.79 [95% CI 0.34-1.83] for H3N2, and OR 0.79 [95% CI 0.37-1.70] for B). For MTX, results differed depending on the method of analysis (222 patients; OR 0.35 [95% CI 0.18-0.66] for at least 2 strains, ORs were close to 1.0 in the single strain analysis). Pneumococcal vaccination response was reduced for 139 patients receiving MTX compared with controls (OR 0.33 [95% CI 0.20-0.54] for serotype 6B and OR 0.58 [95% CI 0.36-0.94] for 23F) but not for anti-TNFα (258 patients; OR 0.96 [95% CI 0.57-1.59] for 6B and OR 1.20 [95% CI 0.57-2.54] for 23F). For RTX, the response was reduced (88 patients; OR 0.25 [95% CI 0.11-0.58] for 6B and OR 0.21 [95% CI 0.04-1.05] for 23F).

CONCLUSION

MTX decreases humoral response to pneumococcal vaccination and may impair response to influenza vaccination. The immune response to both vaccines is reduced with RTX but not with anti-TNFα therapy in RA patients.

[Vaccination in patients from Brasília cohort with early rheumatoid arthritis]

INTRODUCTION

Patients with a diagnosis of rheumatoid arthritis (RA) are at increased risk of infections. Vaccination is a recommended preventive measure. There are no studies evaluating the practice of vaccination in patients with early RA.

OBJECTIVES

To evaluate the frequency of vaccination and the orientation (by the doctor) about vaccines among patients with early RA diagnosis.

METHODS

Cross-sectional study including patients from the early RA Brasilia cohort. Demographic data, disease activity index (Disease Activity Score 28 - DAS28), functional disability (Health Assessment Questionnaire - HAQ), and data on treatment and vaccination after diagnosis of RA were analyzed.

RESULTS

68 patients were evaluated, 94.1% women, mean age 50.7±13.2 years. DAS28 was 3.65±1.64, and HAQ was 0.70. Most patients (63%) had vaccination card. Only five patients (7.3%) were briefed by the doctor about the use of vaccines. Patients were vaccinated for MMR (8.8%), tetanus (44%), yellow fever (44%), hepatitis B (22%), influenza (42%), H1N1 (61.76%), pneumonia (1.4%), meningitis (1.4%), and chickenpox (1.4%). All patients vaccinated with live attenuated virus were undergoing immunosuppressive therapy, and were vaccinated inadvertently, without medical supervision. There was no association between the use of any vaccine and disease activity, functional disability, years of education, lifestyle, and comorbidities.

CONCLUSION

Patients were infrequently briefed by the physician regarding use of vaccines, with high frequency of inadvertent vaccination with live attenuated component, while immunization with killed virus was below the recommended level.

Vaccination against seasonal influenza is effective in Japanese patients with rheumatoid arthritis enrolled in a large observational cohort

OBJECTIVE

To investigate the effectiveness of influenza vaccination in patients with rheumatoid arthritis (RA) from a large practice-based cohort.

METHOD

Patients with RA enrolled in the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort completed self-administered questionnaires as part of the April IORRA surveys of 2001, 2002, 2003, and 2007, which included their influenza vaccination status and occurrence of an actual influenza attack. Vaccine coverage rate and attack rates were calculated in each season. Relative risks (RRs) of vaccination for an actual influenza attack were evaluated and risk factors for influenza infection were determined by multiple logistic regression analysis.

RESULTS

Data from 3529, 4518, 4816, and 4872 patients in the 2000/01, 2001/02, 2002/03, and 2006/07 seasons, respectively, were analysed. Coverage rates were increased from 12.2% in the 2000/01 season to 38.7% in the 2006/07 season. For each season, the attack rates in vaccinated patients trended lower than the rates in unvaccinated patients but the differences were not significant; however, by combining these four seasonal results, the attack rate was significantly lower for vaccinated patients [RR 0.83, 95% confidence interval (CI) 0.71-0.95, p < 0.01]. Male gender [odds ratio (OR) 1.48, 95% CI 1.25-1.76, p < 0.001] was associated with increased risk whereas vaccination was associated with reduced risk for influenza attack (OR 0.76, 95% CI 0.63-0.91, p < 0.01). There were no associations between influenza attacks and RA disease activity, treatment with methotrexate (MTX) or corticosteroids.

CONCLUSION

Influenza vaccination was effective in patients with RA regardless of disease activity or treatment.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Routinely measuring and reporting pneumococcal vaccination among immunosuppressed rheumatology outpatients: the first step in improving quality

OBJECTIVE

The Centers for Disease Control (CDC) recommends pneumococcal vaccination for immunocompromised patients. Data suggest that rates of vaccination in this population are not optimal. To support continuous quality improvement efforts, we electronically measured vaccination status among rheumatology outpatients over time.

METHODS

Using data from administrative (billing) and electronic health record sources, we identified rheumatology clinic patients seen between 1 February 2008 and 31 January 2010 and prescribed an immunosuppressive medication. CDC recommendations for pneumococcal vaccination were applied. We calculated the proportion of eligible patients who were up-to-date with pneumococcal vaccination: (i) while on an immunosuppressive medication and (ii) before newly starting an immunosuppressive medication in the last 12 months.

RESULTS

We identified 2763 rheumatology clinic patients on immunosuppressive medications, with 568 initiated in the last 12 months. The mean age was 57 years, 75% were female and 77% were Caucasian. The most frequent disease was RA (50%) and the most common immunosuppressive medication was MTX (59%). Of patients on immunosuppressive medications, 1491/2763 (54%) were up to date with pneumococcal vaccination. Among new initiators of immunosuppressive medications, 258/568 (45%) were vaccinated before starting the immunosuppressive medication. Patients treated by rheumatologists in practice for ≤10 years were more likely to be up to date with pneumococcal vaccination (72%) than those with providers in practice >10 years (52%, P < 0.001).

CONCLUSION

The proportion of patients who are up to date with documented pneumococcal vaccination was suboptimal in our rheumatology practice. The ability to continuously repeat electronic measurement permits us to initiate continuous quality improvement efforts.

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

PURPOSE AND OBJECTIVES

The patients using immunosuppressive agents are considered at high risk for acquiring different infections. Accordingly, international guidelines recommend vaccinating such patients against influenza and pneumococcal organisms. The aims of this study were two-fold: (1) to assess the influenza and pneumococcal vaccination uptake among our rheumatology outpatients who are immunosuppressed; (2) to identify the factors influencing immunisation uptake among our sample of patients.

METHODS

This was a questionnaire-based study. Patients were eligible to partake in this study if they were using immunosuppressive drugs. During the study period (4 weeks), 337 patients were screened, and 110 patients fulfilled the criteria for inclusion.

RESULTS

Positive vaccination uptake of our cohort was as follows: common influenza alone (34%, 37 out of 110), pneumonia alone (11%, 12 out of 110), and both pneumococcal and influenza vaccination (11%). The status of influenza A (H1N1) vaccination was not recorded as a part of this audit. The two most common reasons cited by patients for non-uptake of vaccinations were: 'not offered' and 'thought it was unnecessary'. Of 37 patients who had influenza vaccination, 33 patients (89%) had additional risk factors, and there were only four patients who had influenza vaccine solely because they were taking immunosuppressive drugs. All pneumococcal vaccinated patients (n=12) were noted to have additional risk factors.

CONCLUSION

There is suboptimal uptake of influenza and pneumococcal vaccinations among immunosuppressed patients attending rheumatology outpatient clinics. These results are a cause of concern given the morbidity and mortality of associated infections.

[Recommendations for the management of influenza A (H1N1) in rheumatic patients with immunosuppression]

The Spanish Society of Rheumatology (SER), through a multidiscipline task force, has elaborated a document with specific recommendations for specialists in Rheumatology, emphasizing the special needs of patients with rheumatic diseases, with the objective of informing and orienting health professionals about the current influenza A/H1N1 virus pandemic. All of the recommendations are based on prior documents elaborated by the Ministry of Health and Social Policy task forces, as well as those from the autonomous communities, which are themselves based on the guidelines and documents routinely published by the Centers for Disease Control (CDC) in the US, this being the center designated by WHO for the coordination of efforts against the pandemic. All rheumatologists and potential users of these recommendations are encouraged to consult the original documents, as well as the general guidelines established at each health center.

Vacinação contra febre amarela em pacientes com diagnósticos de doenças reumáticas, em uso de imunossupressores

A febre amarela é endêmica em alguns países. A vacina, único modo eficaz de proteção, é contra-indicada em pacientes imunocomprometidos. Nosso objetivo é relatar uma série de casos de pacientes reumatológicos, usuários de imunossupressores, vacinados contra a doença. Foi feito um estudo retrospectivo, por meio de questionário aplicado em pacientes reumatológicos medicados com imunossupressores, vacinados 60 dias antes da investigação. Foram avaliados 70 pacientes, com idade média de 46 anos, 90% mulheres, portadores de artrite reumatóide (54), lupus eritematoso sistêmico (11), espondiloartropatias (5) e esclerose sistêmica (2). Os esquemas terapêuticos incluíam metotrexato (42), corticoesteróides (22), sulfassalazina (26), leflunomida (18), ciclofosfamida (3) e imunobiológicos (9). Dezesseis (22,5%) pacientes relataram efeitos adversos menores. Dentre os 8 pacientes, em uso de imunobiológicos, apenas um apresentou efeito adverso, leve. Entre pacientes em uso de imunussopressores, reações adversas não foram mais freqüentes do que em imunocompetentes. Este é o primeiro estudo sobre o tema.

Corticothérapie systémique et risque infectieux

PURPOSE

It was shown that corticosteroids alter the inflammatory and immune responses. Many publications report on serious infections occurring in patients receiving corticosteroids or presenting with Cushing's syndrome. This information is synthesized in this article.

CURRENT KNOWLEDGE AND KEY POINTS

The demonstration of the infectious risk associated with corticosteroids relies on observational data and on biological plausibility. However, this risk remains difficult to quantify, because of many confusing factors such as the patients' associated conditions and immunosuppressive treatments, and the highly variable dose and duration of the corticosteroid treatment. Taking into account the published data, the screening for a chronic infection seems licit among patients receiving a systemic corticosteroid treatment, in particular for those who will receive more than 10 mg of prednisone per day.

FUTURE PROSPECTS

Although no clinical trials of prevention of infections in corticosteroid treated patients has been published, a strategy aiming at minimizing the infectious risk of corticosteroid treated patients is proposed, based on the analysis of the literature presented in this article.

Impfungen in der Erwachsenenrheumatologie

Patients with rheumatic diseases who are undergoing immunosuppressive therapy have a substantially increased risk of infection compared to the normal population, and are thus candidates for preventive measures. In accordance with the recommendations of the Standing Vaccination Commission of the Robert Koch Institute (Ständigen Impfkommission, STIKO), these individuals, in analogy with other patients with chronic diseases, belong to a risk group for which vaccination against pneumococci and influenza is recommended. Published studies indicate that a limited immune response is possible for patients undergoing immunosuppressive therapy. Here, methotrexate in particular appears to interfere with the success of vaccination against pneumococci. However, a limited immune response against influenza antigens was observed under immunosuppression with mycophenolate mufti, cyclosporine und azathioprine. Consideration must be given to the fact that a patient under continual immunosuppression has a reduced duration of protective immune response. New studies on tumor necrosis factor (TNF) inhibitors indicate that there should be no interference with pneumococcus infection. The possibly variable vaccination success of patients undergoing TNF inhibitor treatment is qualified by the fact that all published results show that the expected immune response after an influenza vaccination is very good. Vaccination strategies in cases in which the use of rituximab and abatacept is planned are currently unclear.

Guidelines for assessing immunocompetency in clinical trials for autoimmune diseases

Clinical trials testing the safety and efficacy of immunosuppressive agents for the treatment of autoimmune diseases should also be designed to evaluate immunocompetency. The most clinically relevant outcome for assessing immunocompetency is the infection rate. Therefore, a systematic approach to screening, monitoring, and reporting infections, modeled after the recommendations of the American Society of Transplantation, is presented. However, because the baseline infection rate in most autoimmune diseases is low, additional tests for immunocompetency should be considered. Evaluation of vaccine responses, an alternative clinically relevant approach, may be particularly useful. Other adjunctive approaches to evaluation of immunocompetency are discussed including immunization with non-vaccine neoantigens, surveillance of chronic viral infections, in vivo or in vitro assessment of cellular immunity, and analysis of innate immunity. Banking genetic material to allow genotyping should be considered particularly if a central repository for samples from different trials can be established.

Influenza vaccination in systemic lupus erythematosus: safe and protective?

Patients with systemic lupus erythematosus (SLE) show decreased immune responsiveness and are vulnerable for infectious diseases, due to the underlying disease and the frequent use of immunosuppressive drugs. Influenza has a high incidence in the population and is associated with increased morbidity and mortality in immunocompromised patients. Therefore, routine influenza vaccination of SLE patients seems indicated. However, there have been concerns about the safety of influenza vaccination in SLE as vaccination was thought to activate the autoimmune response. Safety of influenza vaccination has been studied, and, as far as SLE patients with quiescent disease are concerned, it is now generally accepted that influenza vaccination is safe. Another point of concern is vaccine efficacy. In immunocompromised patients, the immunogenicity of vaccines may be reduced. In the immune response to influenza (vaccination) both humoral and cell-mediated responses are involved. In SLE, research on the immune response to influenza vaccination has focused on humoral immune responses, demonstrating a blunted humoral response. Future research should focus on cell-mediated immune responses as well, as these are important for clearing of influenza infection and are expected to be impaired in SLE. Because of the decreased immunogenicity of the current influenza vaccine in SLE, new influenza vaccination strategies should be explored to improve vaccination efficacy.