Abstract
In the past two decades, rheumatology has witnessed a paradigm shift—from the widespread use of methotrexate and leflunomide to the advent of biologics, biosimilars, and now targeted small molecules that have revolutionized treatment. However, this progress comes with a significant challenge: infections, which remain a pressing concern in India, where we face unique socioeconomic and healthcare challenges. The holistic management of autoimmune rheumatic diseases (AIRDs) must go beyond disease control to focus on preventing complications, with infection prevention, particularly through vaccination, being of utmost importance.
In this context, the publication of the “Expert Panel Consensus Statements on Vaccination for Adults with AIRD in India” is a welcome step. 1 It reflects a well-coordinated effort to provide consensus-based, up-to-date recommendations aligned with global standards for AIRD patients in India. Authors have done well in allaying common fears in the rheumatology community by providing evidence-based guidelines for initiating vaccinations, across all the ages, before initiation of immunosuppressive therapy even in active AIRDs. Regarding pneumococcal vaccination, present guidelines have highlighted that both, pneumococcal polysaccharide vaccine (PPSV23) or PCV13, are equally efficacious in generating sufficient antibody responses and can be used as stand alone or in prime boost manner (PCV13 followed 2 months later by PPSV23). However, guidelines are not clear about certain real-world scenarios; a patient received a dose of pneumococcal polysaccharide vaccine (PPSV23) five years ago then what should be administered next—PPSV23 or PCV13, and in what sequence—especially when the patient’s prior PCV13 status is unknown, a frequent occurrence in India. Perhaps, till more data is available for such scenarios, rheumatologists should use their own best judgement in vaccinating their patients. Readers may refer to our 2010 paper that may offer practical, simplified guidance on pneumococcal vaccination, addressing these very issues with a clear schedule and case examples. 2 Even the European League Against Rheumatism (EULAR) dedicated a table to this, underscoring its importance. 3
Cervical cancer remains the second leading cause of cancer-related deaths among Indian women, with over 25% of global deaths occurring in India. The WHO, endorsed by the Federation of Obstetric and Gynecological Societies of India (FOGSI), strongly recommends HPV vaccination for girls under 15 years, with two doses at a six-month interval, and for immunocompromised women up to 45 years of age. 4 Given the high prevalence of women with AIRD in India, HPV vaccination should be given significant attention. Authors of the current guidelines have cited lack of good quality data regarding recommendations for HPV vaccination in patients with AIRDs. Again, readers may refer either to FOGSI guidelines or to our 2010 paper. 2 With the availability of good quality studies it is expected that this crucial area will be updated in the future guidelines.
Another aspect that requires attention is the vaccination of neonates born to mothers with active AIRD. Increasingly, women with rheumatic diseases are able to conceive and carry pregnancies to term due to the safety of several drugs, including anti-TNF agents. However, after delivery, these mothers often rely on pediatricians or obstetricians who may not be fully aware of the nuances involved in vaccinating these infants. Both the European Alliance of Associations for Rheumatology (EULAR) and the American College of Rheumatology (ACR) have clear guidelines on when to avoid live vaccines in neonates born to mothers receiving certain immunosuppressive treatments.3,5 Unfortunately, this crucial information is not addressed in the current IRAVAC consensus paper.
Another notable oversight by the Expert Panel is the omission of key insights from an Indian paper, also published in this journal in 2016, which offers clear recommendations on vaccination for adults with autoimmune inflammatory rheumatic diseases (AIRD). 6 Also an ‘ACR recommendations’ publication on vaccination for adults with autoimmune inflammatory rheumatic diseases has been missed in IRAVAC consensus paper. 7 Incorporating some of the crucial points of these recommendations into the IRAVAC consensus statement 1 would have enhanced its practical utility for this special patient population.
Lastly, while the literature on timing the cessation of immunosuppressive therapy before administering live vaccines is limited, it is worth noting that the ACR provides detailed and practical guidance on this, offering specific intervals for each drug. 5 A similar effort by the authors here would have been highly appreciated.
As we move toward more localized guidelines, we must ensure that they are not only comprehensive but also practical and cost-effective for rheumatologists treating patients from diverse socioeconomic backgrounds. Guidelines should serve as a ready reckoner for the busy clinician, providing clear recommendations on which vaccine to use, when to use it, and how to use it.
We are hopeful that future updates to these consensus statements will address these shortcomings. A clear, more comprehensive and user-friendly approach to this issue would be a significant improvement.
We look forward to the next iteration of these guidelines, which will hopefully address these critical gaps.