Vaccinations in rheumatology

Two things make vaccination more important, not less, for people with inflammatory rheumatic disease. The first is the condition itself: an immune system that is overactive against the joints can be less effective against some infections, and inflammatory disease can make certain infections more likely or more severe. The second is the treatment. The DMARDs, biologics and JAK inhibitors and steroids that control the disease all work by quietening the immune system, and a quieter immune system is a little less able to fend off infection. Prevention therefore counts for more here than it does for the general population, and vaccination is prevention you can plan.

It helps to clear up a worry at the outset. Vaccines do not use up the immune system or wear it out, and they do not make the underlying rheumatic condition worse. A vaccine simply shows the immune system a harmless preview of an infection so that it can respond faster if the real thing arrives. Large studies have looked specifically for vaccine-triggered flares and have been reassuring: the vaccines discussed here do not typically set off a flare of arthritis. The benefit, a lower chance of an infection that could set your treatment back, is real and well established.

Almost everything about vaccination on immune-suppressing treatment comes down to one distinction, so it is worth understanding it well.

Non-live vaccines contain no living organism. They may hold an inactivated (killed) version of a germ, a fragment of one, or the instructions for the body to make a single harmless piece of it. Because there is nothing living to multiply, they cannot cause the infection they protect against, even when the immune system is suppressed. These vaccines are safe on immunosuppressive treatment and are actively encouraged. The annual flu jab, the COVID-19 vaccines, the pneumococcal vaccine and the shingles vaccine now used in the UK programme are all non-live.

Live (attenuated) vaccines contain a weakened but still living form of the organism. In most people it is too weak to cause illness, but if the immune system is significantly suppressed it can occasionally cause the very infection it was meant to prevent. For that reason live vaccines are generally avoided during significant immunosuppression and should never be given without specialist advice first. Live vaccines include MMR (measles, mumps and rubella), the nasal spray flu vaccine used mainly in children, BCG (against tuberculosis), yellow fever, oral typhoid, and the older live shingles vaccine.

The shingles vaccine is the clearest illustration of why the label matters more than the name. An older shingles vaccine was live, and would have been avoided on immunosuppression; the vaccine now used in the UK is a non-live version and is suitable for many people who could not have had the old one. Same disease, opposite advice, because one is live and the other is not. If you are ever unsure which type a particular vaccine is, ask before having it rather than after.

For most people on treatment, four vaccinations do the everyday work of protection, and all four are non-live.

• Influenza, given every year, because the flu virus changes and last year's protection fades. Flu can be more serious in people on immune-suppressing treatment, which is why the yearly jab is recommended rather than optional.
• COVID-19, kept up to date as advised, for the same reason.
• Pneumococcal, which protects against a common cause of pneumonia and other serious infections.
• Shingles, using the non-live vaccine, which protects against a painful reactivation of the chickenpox virus that becomes more likely as immunity wanes or is suppressed.

Who is eligible for each of these, and when, is decided by national UK vaccination programmes rather than by any individual clinic, and those rules are reviewed and change over time. The shingles programme in particular has changed in recent years, both in which vaccine is used and in who is offered it, so it is worth checking your current eligibility rather than relying on what was true a few years ago. One example: the non-live shingles vaccine is now offered to adults with a severely weakened immune system from the age of 18, rather than only from 50, which brings it within reach of many younger people on immune-suppressing treatment. Most of these vaccines are arranged through your GP surgery or practice nurse; your rheumatology team's part is to advise on timing and on anything specific to your treatment.

Timing can make a real difference to how well a vaccine works, and it is one of the practical reasons to raise vaccination early.

Wherever possible, vaccinations are best brought up to date before immune-suppressing treatment begins. This matters most for live vaccines, which may not be an option once treatment is under way, and it also gives non-live vaccines the best chance of producing a strong response while the immune system is still at full strength. When a new medicine such as a biologic is being planned, checking and completing vaccinations is part of getting ready for it, as covered in our guide to biologics and JAK inhibitors.

Once you are already on treatment, non-live vaccines are still very much worth having. The immune response to them can be somewhat reduced by immunosuppression, so the protection may be a little less complete than it would be otherwise, but a slightly smaller benefit is still a benefit, and these vaccines remain recommended. Two specific points come up often enough to mention, both as background rather than instructions:

• Rituximab, a biologic that works by depleting immune B cells, blunts the response to vaccines for a period, so the timing of vaccination relative to it is planned deliberately by the specialist team.
• Methotrexate: there is good evidence that briefly pausing methotrexate around the time of some vaccinations, such as the flu vaccine, can improve the immune response to them. This is a decision made with your rheumatology team, and only by them. It is never a reason to stop or skip your treatment on your own.

The principle behind both is the same: small adjustments in timing, made by the people who know your treatment, can get more out of a vaccine without putting your disease control at risk.

A common and reasonable worry is whether being on immune-suppressing treatment restricts the vaccines your family can have. For the most part it does not. Household members and close contacts can have their own routine vaccinations, including most live ones, in the normal way, and keeping the people around you well protected is one of the ways they help protect you.

There are a small number of sensible cautions rather than blanket bans, and these are worth checking with your team:

• Children in the household are offered the live nasal spray flu vaccine. This is generally fine around someone on immunosuppression; only in specific situations of very severe immunosuppression is any extra precaution suggested, and the injected flu vaccine is an alternative for the child if needed.
• After certain live vaccines a person can briefly shed the weakened organism, so ordinary hygiene, such as careful handwashing, and avoiding direct contact with any vaccine rash for a short time, is occasionally advised.

None of this means keeping your distance from vaccinated family members. It means a few specific, time-limited precautions in particular circumstances, which your team can spell out for your situation.

Travel vaccination needs extra thought, because some travel vaccines are live. Yellow fever vaccine is the important example: it is a live vaccine, often required for entry to certain countries, and it is generally not given during significant immunosuppression. If you are planning to travel, start the conversation well ahead of time, ideally weeks to months, so that your rheumatology team and a travel clinic can work out which vaccines you need, which are safe for you, and how to time them. Where a live travel vaccine cannot be given, a certificate exemption letter is sometimes arranged instead, so that entry requirements can still be met. Many other travel vaccines are non-live and present no such difficulty.

Vaccination in pregnancy has its own set of considerations, both for the vaccines themselves and for the arthritis treatment around them, and our guide to arthritis, autoimmune conditions and pregnancy is the place to start.

For what to do when you are actually unwell, including whether medicines are paused during an infection, our companion guide to infections and arthritis medicines covers the ground this one does not.

It would be easy to read a page like this and see mainly restrictions: one type of vaccine to avoid, timing to think about, questions to ask. The more useful way to read it is the other way round. The great majority of the vaccines that protect adults are non-live, which means they are open to you and, on treatment that quietens the immune system, more worthwhile than ever. The single rule that really has to stick is the live-vaccine one: check first, because that is where the caution lies. Everything else is planning, and planning is what turns a slightly higher infection risk back into an ordinary life. Bring vaccinations up to date before treatment where you can, keep the yearly and routine ones going once you are on it, ask before any live vaccine or trip abroad, and let your team handle the timing. Done that way, vaccination is one of the simplest and most effective things you can do to keep your treatment working and yourself well.

What is the difference between a live and a non-live vaccine, and why does it matter so much?

It is the single most important distinction on this page. Non-live vaccines contain no living organism, so they cannot cause the infection they protect against, even when the immune system is suppressed; these are safe on immune-suppressing treatment and are encouraged, and they include the flu, COVID-19, pneumococcal and current UK shingles vaccines. Live vaccines contain a weakened but still living organism, which can occasionally cause the very infection it protects against during significant immunosuppression, so they are generally avoided and need specialist advice before you have them. Live vaccines include MMR, yellow fever, BCG and the nasal spray flu vaccine given to children. Our guide to infections and arthritis medicines is the companion to this one.

Will having a vaccine make my arthritis flare or wear out my immune system?

No on both counts. A vaccine does not use up or wear out the immune system; it simply shows it a harmless preview of an infection so it can respond faster later. Nor does it make the underlying rheumatic condition worse. Large studies have looked specifically for vaccine-triggered flares and have been reassuring: the vaccines discussed here do not typically set off a flare. The worthwhile benefit is a lower chance of an infection that could set your treatment back.

Which vaccines should I keep up to date, and who arranges them?

For most people on treatment, four non-live vaccines do the everyday work: the annual flu jab, COVID-19 kept up to date as advised, the pneumococcal vaccine, and the shingles vaccine now used in the UK. Who is eligible, and when, is set by national UK programmes rather than by any clinic, and those rules change over time, so it is worth checking your current eligibility rather than assuming; the shingles programme in particular has changed in recent years. These are usually arranged through your GP surgery or practice nurse, while your rheumatology team advises on timing.

Should I stop my methotrexate or biologic around a vaccination?

Not on your own, and not without specialist advice. There is good evidence that briefly pausing methotrexate around some vaccinations, such as the flu vaccine, can improve the response to them, but that is a decision your rheumatology team makes with you, never an instruction to stop treatment yourself. Timing also matters for some biologics: rituximab in particular blunts vaccine responses for a period, so vaccination around it is planned deliberately. The safe approach is to raise vaccination at a review and let the team plan the timing.

Can my family have their normal vaccinations, and what about travelling abroad?

Yes: household members and close contacts can have their own routine vaccinations, including most live ones, in the normal way, and keeping them well protected helps protect you. A few specific cautions exist rather than blanket bans, such as around the live nasal spray flu vaccine in children and brief hygiene precautions after certain live vaccines, which your team can spell out. Travel needs more planning, because some travel vaccines, such as yellow fever, are live and are generally not given during significant immunosuppression, so start the conversation weeks to months ahead.