Editorial

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J Rheum Dis 2023; 30(2): 69-71

Published online April 1, 2023

© Korean College of Rheumatology

Vaccination of patients with autoimmune inflammatory rheumatic disease: physicians’ perspectives

Ki Won Moon , M.D., Ph.D.

Division of Rheumatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea

Correspondence to : Ki Won Moon, https://orcid.org/0000-0002-4182-8328
Division of Rheumatology, Department of Internal Medicine, Kangwon National University School of Medicine, 1 Gangwondaehak-gil, Chuncheon 24341, Korea. E-mail: kiwonmoon@kangwon.ac.kr

Received: March 8, 2023; Accepted: March 10, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Infectious disease is one of the leading causes of morbidity and mortality in patients with autoimmune inflammatory rheumatic disease (AIIRD). The risk of infection is high in various rheumatic diseases including rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, polymyositis, and dermatomyositis [1,2]. The vulnerability for infections in patients with AIIRD was considered to be via alteration of immunoregulation, disease severity, combined diseases, and immunosuppressive agents [3]. Furer et al. [4] reported patients with AIIRD to be associated with an increased risk of vaccine preventable infections including influenza, pneumococcal, herpes zoster, and human papillomavirus infections. There have been several vaccination guidelines for patients with AIIRD. The American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) periodically announce vaccination guidelines for patients with AIIRD [5,6]. In Korea, there was a practice guideline for vaccinating Korean patients with AIIRD [7]. However, the real-world data showed that the vaccination coverage rate for patients with AIIRD is low [8,9]. There may be several reasons for low vaccination rate. First, the cause can be considered to arise from the patient’s perspective. A study from Australia reported that vaccine hesitancy in patients with inflammatory arthritis was caused by uncertainty and lack of information about which vaccines were recommended [10]; only 43% of patients knew which vaccines were recommended for them. In case of COVID-19 vaccine, concerns about the side-effects, safety, and rapid development of vaccines made patients with AIIRD reluctant to receive the vaccine [11]. In addition, there was a concern about disease flare after COVID-19 vaccination. Nevertheless, COVID-19 vaccine was recommended for patients with AIIRD because the benefits of vaccination outweigh the potential risks [12].

In addition to the patients’ cause, factors related to the physician seem to contribute to the low vaccination rate. Seo et al. [13] reported the results of the physician’s agreement and implementation of the 2019 EULAR vaccination guideline. They received answers from 371 healthcare professionals from various continents including Asia, North America, Europe, and South America. The rate of physician’s agreement for most of the 2019 EULAR vaccination guidelines was high, except for a few items; however the rate of implementation was low. This implies that there was a discrepancy between their knowledge and actual practice, which may be due to various reasons. As the authors indicated, it is possible that the rheumatologists do not prioritize vaccination in their routine clinical practice. Some recommendations are not followed well in practice because of physicians’ disagreement or their unfamiliarity with those items, such as live-attenuated vaccines and yellow fever vaccine. In another study, they analyzed the reasons for non-adherence of physicians to the vaccination guidelines [14]. The main causes of non-adherence were lack of time and inexperience with vaccination. The most interesting part of that study was that the patient volume per clinic session and medical care setting were not associated with the vaccination rate. In addition, the study presented the difference in perspectives on who was primarily responsible for vaccination according to continents. Only approximately 40% of participants in Europe and North America responded that rheumatologists were primarily responsible for vaccination. In contrast, over 70% of participants in Asia answered that rheumatologists have a primary responsibility.

We have been through the pandemic of COVID-19 for 3 years. Despite the many myths, misunderstandings, and inaccuracies in the knowledge about COVID-19 vaccine, it cannot be denied that vaccination was effective in reducing the morbidity and mortality rate. As suggested by various vaccination guidelines, rheumatologists should take charge of the vaccination for patients with AIIRD [6,15]. The rate of vaccination coverage can be increased through several methods. It is necessary that vaccination records be included in the initial assessment and the need for further vaccination be assessed yearly. Institutional support can improve the clinical situation. A study by Seo et al. [14] showed that lack of time was the main cause of non-adherence to vaccination guidelines. If the number of consultation hours per patient increases, physicians can pay more attention to the vaccination status. Moreover, an electronic decision support system can be helpful. A study revealed that the electronic identification and alert system in electronic health records significantly improved the pneumococcal vaccination rate [16]. Thus, a change in the perspective and efforts of the physician are important. Correct information and individualized plan of vaccination should be provided to the patients, and a shared decision making between physicians and patients should be encouraged. These multidisciplinary efforts can improve the rate of vaccination coverage for patients with AIIRD.

K.W.M. has been an editorial board member since June 2022, but has no role in the decision to publish this article.

  1. Mehta B, Pedro S, Ozen G, Kalil A, Wolfe F, Mikuls T, et al. Serious infection risk in rheumatoid arthritis compared with non-inflammatory rheumatic and musculoskeletal diseases: a US national cohort study. RMD Open 2019;5:e000935.
    Pubmed KoreaMed CrossRef
  2. Alarcón GS. Infections in systemic connective tissue diseases: systemic lupus erythematosus, scleroderma, and polymyositis/dermatomyositis. Infect Dis Clin North Am 2006;20:849-75.
    Pubmed CrossRef
  3. Cunnane G, Doran M, Bresnihan B. Infections and biological therapy in rheumatoid arthritis. Best Pract Res Clin Rheumatol 2003;17:345-63.
    Pubmed CrossRef
  4. Furer V, Rondaan C, Heijstek M, van Assen S, Bijl M, Agmon-Levin N, et al. Incidence and prevalence of vaccine preventable infections in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD): a systemic literature review informing the 2019 update of the EULAR recommendations for vaccination in adult patients with AIIRD. RMD Open 2019;5:e001041.
    Pubmed KoreaMed CrossRef
  5. Bass AR, Chakravarty E, Akl EA, Bingham CO, Calabrese L, Cappelli LC, et al. 2022 American College of Rheumatology guideline for vaccinations in patients with rheumatic and musculoskeletal diseases. Arthritis Care Res (Hoboken) 2023;75:449-64.
    Pubmed CrossRef
  6. Furer V, Rondaan C, Heijstek MW, Agmon-Levin N, van Assen S, Bijl M, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2020;79:39-52.
    Pubmed CrossRef
  7. Seo YB, Moon SJ, Jeon CH, Song JY, Sung YK, Jeong SJ, et al. The practice guideline for vaccinating Korean patients with autoimmune inflammatory rheumatic disease. Infect Chemother 2020;52:252-80.
    Pubmed KoreaMed CrossRef
  8. Krasselt M, Ivanov JP, Baerwald C, Seifert O. Low vaccination rates among patients with rheumatoid arthritis in a German outpatient clinic. Rheumatol Int 2017;37:229-37.
    Pubmed CrossRef
  9. Subesinghe S, Rutherford AI, Ibrahim F, Harris H, Galloway J. A large two-centre study in to rates of influenza and pneumococcal vaccination and infection burden in rheumatoid arthritis in the UK. BMC Musculoskelet Disord 2016;17:322.
    Pubmed KoreaMed CrossRef
  10. Lyon A, Quinlivan A, Lester S, Barrett C, Whittle SL, Rowett D, et al. Vaccination rates, perceptions, and information sources used by people with inflammatory arthritis. ACR Open Rheumatol 2023;5:84-92.
    Pubmed KoreaMed CrossRef
  11. Putman M, Kennedy K, Sirotich E, Liew JW, Sattui SE, Moni TT, et al. COVID-19 vaccine perceptions and uptake: results from the COVID-19 Global Rheumatology Alliance Vaccine Survey. Lancet Rheumatol 2022;4:e237-40.
  12. Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, et al. American College of Rheumatology guidance for COVID-19 vaccination in patients with rheumatic and musculoskeletal diseases: version 5. Arthritis Rheumatol 2023;75:E1-16.
    Pubmed KoreaMed CrossRef
  13. Seo P, Winthrop K, Sawalha AH, Choi S, Hwang W, Park HA, et al. Physicians’ agreement on and implementation of the 2019 European Alliance of Associations for Rheumatology vaccination guideline: an international survey. J Rheum Dis 2023;30:18-25.
    CrossRef
  14. Seo P, Winthrop K, Sawalha AH, Choi S, Park HA, Hwang W, et al. Physician perspectives on vaccination in patients with autoimmune inflammatory rheumatic diseases: an international survey. J Rheumatol 2023;50:246-51.
    Pubmed CrossRef
  15. Park JK, Lee EB, Shin K, Sung YK, Kim TH, Kwon SR, et al. COVID-19 vaccination in patients with autoimmune inflammatory rheumatic diseases: clinical guidance of the Korean College of Rheumatology. J Korean Med Sci 2021;36:e95. Erratum in: J Korean Med Sci 2021;36:e270.
    Pubmed KoreaMed CrossRef
  16. Sheth HS, Grimes VD, Rudge D, Ayers B, Moreland LW, Fischer GS, et al. Improving pneumococcal vaccination rates in rheumatology patients by using best practice alerts in the electronic health records. J Rheumatol 2021;48:1472-9.
    Pubmed CrossRef

Article

Editorial

J Rheum Dis 2023; 30(2): 69-71

Published online April 1, 2023 https://doi.org/10.4078/jrd.2023.0017

Copyright © Korean College of Rheumatology.

Vaccination of patients with autoimmune inflammatory rheumatic disease: physicians’ perspectives

Ki Won Moon , M.D., Ph.D.

Division of Rheumatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea

Correspondence to:Ki Won Moon, https://orcid.org/0000-0002-4182-8328
Division of Rheumatology, Department of Internal Medicine, Kangwon National University School of Medicine, 1 Gangwondaehak-gil, Chuncheon 24341, Korea. E-mail: kiwonmoon@kangwon.ac.kr

Received: March 8, 2023; Accepted: March 10, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

Infectious disease is one of the leading causes of morbidity and mortality in patients with autoimmune inflammatory rheumatic disease (AIIRD). The risk of infection is high in various rheumatic diseases including rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, polymyositis, and dermatomyositis [1,2]. The vulnerability for infections in patients with AIIRD was considered to be via alteration of immunoregulation, disease severity, combined diseases, and immunosuppressive agents [3]. Furer et al. [4] reported patients with AIIRD to be associated with an increased risk of vaccine preventable infections including influenza, pneumococcal, herpes zoster, and human papillomavirus infections. There have been several vaccination guidelines for patients with AIIRD. The American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) periodically announce vaccination guidelines for patients with AIIRD [5,6]. In Korea, there was a practice guideline for vaccinating Korean patients with AIIRD [7]. However, the real-world data showed that the vaccination coverage rate for patients with AIIRD is low [8,9]. There may be several reasons for low vaccination rate. First, the cause can be considered to arise from the patient’s perspective. A study from Australia reported that vaccine hesitancy in patients with inflammatory arthritis was caused by uncertainty and lack of information about which vaccines were recommended [10]; only 43% of patients knew which vaccines were recommended for them. In case of COVID-19 vaccine, concerns about the side-effects, safety, and rapid development of vaccines made patients with AIIRD reluctant to receive the vaccine [11]. In addition, there was a concern about disease flare after COVID-19 vaccination. Nevertheless, COVID-19 vaccine was recommended for patients with AIIRD because the benefits of vaccination outweigh the potential risks [12].

In addition to the patients’ cause, factors related to the physician seem to contribute to the low vaccination rate. Seo et al. [13] reported the results of the physician’s agreement and implementation of the 2019 EULAR vaccination guideline. They received answers from 371 healthcare professionals from various continents including Asia, North America, Europe, and South America. The rate of physician’s agreement for most of the 2019 EULAR vaccination guidelines was high, except for a few items; however the rate of implementation was low. This implies that there was a discrepancy between their knowledge and actual practice, which may be due to various reasons. As the authors indicated, it is possible that the rheumatologists do not prioritize vaccination in their routine clinical practice. Some recommendations are not followed well in practice because of physicians’ disagreement or their unfamiliarity with those items, such as live-attenuated vaccines and yellow fever vaccine. In another study, they analyzed the reasons for non-adherence of physicians to the vaccination guidelines [14]. The main causes of non-adherence were lack of time and inexperience with vaccination. The most interesting part of that study was that the patient volume per clinic session and medical care setting were not associated with the vaccination rate. In addition, the study presented the difference in perspectives on who was primarily responsible for vaccination according to continents. Only approximately 40% of participants in Europe and North America responded that rheumatologists were primarily responsible for vaccination. In contrast, over 70% of participants in Asia answered that rheumatologists have a primary responsibility.

We have been through the pandemic of COVID-19 for 3 years. Despite the many myths, misunderstandings, and inaccuracies in the knowledge about COVID-19 vaccine, it cannot be denied that vaccination was effective in reducing the morbidity and mortality rate. As suggested by various vaccination guidelines, rheumatologists should take charge of the vaccination for patients with AIIRD [6,15]. The rate of vaccination coverage can be increased through several methods. It is necessary that vaccination records be included in the initial assessment and the need for further vaccination be assessed yearly. Institutional support can improve the clinical situation. A study by Seo et al. [14] showed that lack of time was the main cause of non-adherence to vaccination guidelines. If the number of consultation hours per patient increases, physicians can pay more attention to the vaccination status. Moreover, an electronic decision support system can be helpful. A study revealed that the electronic identification and alert system in electronic health records significantly improved the pneumococcal vaccination rate [16]. Thus, a change in the perspective and efforts of the physician are important. Correct information and individualized plan of vaccination should be provided to the patients, and a shared decision making between physicians and patients should be encouraged. These multidisciplinary efforts can improve the rate of vaccination coverage for patients with AIIRD.

ACKNOWLEDGMENTS

None.

FUNDING

None.

CONFLICT OF INTEREST

K.W.M. has been an editorial board member since June 2022, but has no role in the decision to publish this article.

References

  1. Mehta B, Pedro S, Ozen G, Kalil A, Wolfe F, Mikuls T, et al. Serious infection risk in rheumatoid arthritis compared with non-inflammatory rheumatic and musculoskeletal diseases: a US national cohort study. RMD Open 2019;5:e000935.
    Pubmed KoreaMed CrossRef
  2. Alarcón GS. Infections in systemic connective tissue diseases: systemic lupus erythematosus, scleroderma, and polymyositis/dermatomyositis. Infect Dis Clin North Am 2006;20:849-75.
    Pubmed CrossRef
  3. Cunnane G, Doran M, Bresnihan B. Infections and biological therapy in rheumatoid arthritis. Best Pract Res Clin Rheumatol 2003;17:345-63.
    Pubmed CrossRef
  4. Furer V, Rondaan C, Heijstek M, van Assen S, Bijl M, Agmon-Levin N, et al. Incidence and prevalence of vaccine preventable infections in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD): a systemic literature review informing the 2019 update of the EULAR recommendations for vaccination in adult patients with AIIRD. RMD Open 2019;5:e001041.
    Pubmed KoreaMed CrossRef
  5. Bass AR, Chakravarty E, Akl EA, Bingham CO, Calabrese L, Cappelli LC, et al. 2022 American College of Rheumatology guideline for vaccinations in patients with rheumatic and musculoskeletal diseases. Arthritis Care Res (Hoboken) 2023;75:449-64.
    Pubmed CrossRef
  6. Furer V, Rondaan C, Heijstek MW, Agmon-Levin N, van Assen S, Bijl M, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2020;79:39-52.
    Pubmed CrossRef
  7. Seo YB, Moon SJ, Jeon CH, Song JY, Sung YK, Jeong SJ, et al. The practice guideline for vaccinating Korean patients with autoimmune inflammatory rheumatic disease. Infect Chemother 2020;52:252-80.
    Pubmed KoreaMed CrossRef
  8. Krasselt M, Ivanov JP, Baerwald C, Seifert O. Low vaccination rates among patients with rheumatoid arthritis in a German outpatient clinic. Rheumatol Int 2017;37:229-37.
    Pubmed CrossRef
  9. Subesinghe S, Rutherford AI, Ibrahim F, Harris H, Galloway J. A large two-centre study in to rates of influenza and pneumococcal vaccination and infection burden in rheumatoid arthritis in the UK. BMC Musculoskelet Disord 2016;17:322.
    Pubmed KoreaMed CrossRef
  10. Lyon A, Quinlivan A, Lester S, Barrett C, Whittle SL, Rowett D, et al. Vaccination rates, perceptions, and information sources used by people with inflammatory arthritis. ACR Open Rheumatol 2023;5:84-92.
    Pubmed KoreaMed CrossRef
  11. Putman M, Kennedy K, Sirotich E, Liew JW, Sattui SE, Moni TT, et al. COVID-19 vaccine perceptions and uptake: results from the COVID-19 Global Rheumatology Alliance Vaccine Survey. Lancet Rheumatol 2022;4:e237-40.
  12. Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, et al. American College of Rheumatology guidance for COVID-19 vaccination in patients with rheumatic and musculoskeletal diseases: version 5. Arthritis Rheumatol 2023;75:E1-16.
    Pubmed KoreaMed CrossRef
  13. Seo P, Winthrop K, Sawalha AH, Choi S, Hwang W, Park HA, et al. Physicians’ agreement on and implementation of the 2019 European Alliance of Associations for Rheumatology vaccination guideline: an international survey. J Rheum Dis 2023;30:18-25.
    CrossRef
  14. Seo P, Winthrop K, Sawalha AH, Choi S, Park HA, Hwang W, et al. Physician perspectives on vaccination in patients with autoimmune inflammatory rheumatic diseases: an international survey. J Rheumatol 2023;50:246-51.
    Pubmed CrossRef
  15. Park JK, Lee EB, Shin K, Sung YK, Kim TH, Kwon SR, et al. COVID-19 vaccination in patients with autoimmune inflammatory rheumatic diseases: clinical guidance of the Korean College of Rheumatology. J Korean Med Sci 2021;36:e95. Erratum in: J Korean Med Sci 2021;36:e270.
    Pubmed KoreaMed CrossRef
  16. Sheth HS, Grimes VD, Rudge D, Ayers B, Moreland LW, Fischer GS, et al. Improving pneumococcal vaccination rates in rheumatology patients by using best practice alerts in the electronic health records. J Rheumatol 2021;48:1472-9.
    Pubmed CrossRef
JRD
Jul 01, 2024 Vol.31 No.3, pp. 133~189
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