It’s common to have questions about vaccines, especially if you have a rheumatic disease. Dr. Christopher Mecoli, a physician-scientist in the Division of Rheumatology of The Johns Hopkins School of Medicine, answers some common questions.
What myths do you commonly hear pertaining to vaccines in patients with rheumatic diseases, and how do you tackle them?
The two most common concerns I hear from patients are: (1) patients don’t think they can receive vaccines because they are on medications that suppress their immune system, and (2) the concern of “reactivation” of the infection the vaccine is supposed to protect against.
The answer for the first question is relatively straight-forward to address, by providing education and data supporting the safe use of vaccines in patients on immune suppressing medications. The second question can be a bit more difficult if patients have had vaccine-related reactions in the past (for example, flu-like illnesses). I emphasize that the vaccines typically recommended are “dead”/inactivated vaccines, and while there may be some side effects from the immune booster (adjuvant) in the vaccine, they cannot become infected from the vaccine itself. I also emphasize that oftentimes the bad feeling a patient may experience after the vaccine indicates that it is working to help the immune system recognize the bacteria or virus.
This information and knowledge is more important than ever now, particularly given the possibility of a COVID-19 vaccine coming in the next few months.
Why is it important to talk with your doctor about vaccinations and when, ideally, should you have that conversation?
I typically bring up vaccinations in my first couple of visits with patients. Ideally, talking about vaccines should be discussed at the first visit, but oftentimes, a lot of new information is discussed at this first visit, and it can be overwhelming for patients. In these cases, I sometimes defer to the next time they see me.
The three most common vaccines I recommend to patients are the flu (influenza), pneumonia (PCV13, PCV23), and shingles (Shingrix). Given how common these infections are in the U.S., most patients know someone who has had one (or has had one themselves). All three of these infections can really knock a patient down and cause them to feel miserable; shingles in particular has the risk of causing long-term problems with post-herpetic neuralgia and vision complications.
I typically address common misconceptions even if patients themselves don’t bring them up, and then ask the patient open-ended questions to understand if they have any additional perceived barriers, like cost of the vaccine, access, or fear of needles.
Lastly, I find it is helpful to include “vaccines” as a component of my assessment and plan in my clinical note template, to make sure patients are up to date given the need for recurrent vaccinations.
Patients with rheumatic disease are often immunosuppressed from their therapies – how does that change the discussion around vaccines and communicable diseases?
This is extremely important, particularly given an increasing trend to use combination immunosuppressive therapies in some rheumatic diseases. The good thing is there is data to support the benefit of vaccines in patients with rheumatic diseases on different immunosuppressive regimens.
Some patients, for instance, are not aware that simply having a particular rheumatic disease can increase their risk of infection, regardless of whether they are on any immune-suppressing drugs. Add on top of that Disease Modifying Anti-Rheumatic Drugs (DMARD) agents (e.g. methotrexate, azathioprine, or mycophenolate) and biologic therapies, and the risk can increase further.
Given the constraints of many clinic visits today, I’ve found it is helpful to broach the subject in the clinic, but also provide some form of educational materials for the patients to read more from a trusted source.
While some patients find the CDC or Advisory Committee on Immunization Practices (ACIP) websites helpful and informative, often this is not digestible for many. There are many good health system-supported websites discussing the use of vaccines. In our institution, we have set up several patient education videos that we can include in the after-visit summaries and attach links for patients and their families to peruse at their leisure once they get back home.
No matter what kind of rheumatic disease you have, there are likely safe and effective vaccines available for you. If you have questions about your specific condition and vaccines, we encourage you to speak with your rheumatologist.
Dr. Christopher Mecoli is an Assistant Professor and physician-scientist in the Division of Rheumatology. After completing internship and residency training at the University of Pennsylvania in Philadelphia, he completed a fellowship in rheumatology at Johns Hopkins. He specializes in patients with systemic sclerosis and idiopathic inflammatory myopathies. His clinical interests also include scleroderma-related disorders, such as scleromyxedema and coup de sabre, as well as cancer-associated myositis.