The Australian Immunisation Handbook 10th Edition 2013

Persons with autoimmune diseases and other chronic conditions
Persons with autoimmune conditions, such as systemic lupus erythematosus
(SLE), rheumatoid arthritis (RA) and multiple sclerosis (MS), are at higher
risk of infections, including vaccine-preventable diseases, with the associated
potential morbidity and mortality from infection. They are also at risk of
infection due to treatment with immunosuppressive agents such as bDMARDs
and targeted biological therapies. 148 Some diseases can be reactivated during
therapy, so screening for infections such as hepatitis B and tuberculosis should be
undertaken prior to vaccination. 149,150
Overall, theoretical concerns that vaccines exacerbate or cause autoimmune
diseases such as rheumatoid arthritis, type 1 diabetes and multiple sclerosis
have not been substantiated, with sporadic case reports not verified by larger
epidemiological studies. 151-154 However, persons with a history of Guillain-Barré
syndrome (GBS) have an increased likelihood in general of developing GBS
again, and the chance of them coincidentally developing the syndrome following
influenza vaccination may be higher than in persons with no history of GBS.
A small increased risk of GBS was associated historically with one influenza
vaccine in the United States in 1976, but, since then, close surveillance has shown
that GBS has occurred at a very low rate of up to 1 in 1 million doses of influenza
vaccine, if at all. 155
In persons with autoimmune diseases and other chronic conditions,
there is potential for reduced immunogenicity of vaccines, due to both
immunosuppressive therapies and the underlying disease. 156-158 The duration
of immunocompromise may be prolonged and caution must be taken when
considering live vaccines. Inactivated vaccines are recommended, to optimise
protection despite the potential for reduced immunogenicity in some people.
Clinical and laboratory measures of disease activity, and the choice, duration
and dose of immunosuppressive therapies, do not always predict who will
respond poorly to vaccination. 157,159,160 In some instances, due to ongoing risk
of disease, additional vaccine doses may be required, such as pneumococcal
vaccine. Inactivated vaccines such as HPV and dTpa can be administered to
immunocompromised persons. Annual influenza vaccine is also important in
this population and should be administered annually (2 doses in the first year,
1 annually thereafter).
Hypopituitarism is not a contraindication to vaccination if the person is only
receiving physiological corticosteroid replacement, as this is not considered
immunosuppressive. If the person has been unwell and is on high-dose
corticosteroids for more than 1 week, the use of live attenuated vaccines should
be delayed for a minimum of 1 month.
Persons with metabolic diseases should be vaccinated using the routine schedule,
as vaccinations are generally considered safe in these persons. 161 Influenza and
pneumococcal vaccines are recommended for those with metabolic disease. Any
individual concerns should be discussed with the treating metabolic physician.
PART 3 VACCINATION FOR SPECIAL RISK GROUPS 165
3.3 GROUPS WITH SPECIAL
VACCINATION REQUIREMENTS