Low rate of influenza and pneumococcal vaccine coverage in rheumatoid arthritis: Data from the international COMORA cohort
Introduction
Rheumatoid Arthritis (RA) patients are at risk of suffering from infectious diseases including those of the respiratory tract [1], [2]. The mortality related to those events can be up to ten times that of the general population [3] with Streptococcus pneumococcus being considered as one of the main causative pathogens [4]. This increased risk of infectious diseases can be explained by the rheumatoid arthritis itself, other associated comorbidity (chronic obstructive pulmonary disease, diabetes, alcohol, tobacco use) [5] and its treatment. The multiple immunologic effects of the disease process may in part explain why patients with RA are considered immunocompromised and at increased risk of infection [4] but is certainly in large part secondary to the use of immunosuppressive treatment [6].
Regarding the use of vaccines in patients with RA, evidence indicates that pneumococcal and influenza vaccines can be administered without worsening the RA disease [7]. In fact, both influenza and pneumococcal vaccination are safe and immunogenic in patients with rheumatic diseases [8], [9], although in some cases their immunogenicity is limited by both the disease itself and by treatment with classical disease-modifying anti-rheumatic drugs (cDMARDS) and biological disease-modifying anti-rheumatic drugs (bDMARDS) [10]. Despite this contradictory data, immunization in immunocompromised patients is one important strategy for reducing the level of morbidity and mortality linked to the influenza and pneumococcus infection [11], [12].
To date, EULAR and ACR recommendations for the management of RA have determined that these patients should be vaccinated against influenza annually although the exact prevalence, morbidity, and mortality of influenza in patients with RA are unknown [13]. In contrast the pneumococcal vaccine must be given every 5 years [14], [15]. There are two types of pneumococcal vaccine for adults: the non conjugated polysaccharide-based vaccine (PPSV-23), which contains 23 serotypes that cause more than 75% of pneumococcal infections in adults [16], and the recently 13-valent conjugated vaccine (PCV-13), which is potentially more immunogenic. However, data on PCV-13 vaccination in RA patients is still lacking [17].
Although these vaccines have been recommended in RA by ACR and EULAR, there have been limited studies measuring their use outside of the United States and several other countries suggesting their underutilization [18], [19], and to date it is unclear how vaccine use varies across regions or countries.
Therefore, it seems that there is a gap between such evidence, such recommendations and the way RA patients are monitored in daily practice [20]. In this context, our objectives were: Among an international cohort of RA patients, (1) to describe pneumococcal and influenza vaccine coverage (2) and to evaluate factors associated with their use.
Section snippets
Source data
This study is a post hoc analysis of the COMORA cohort [21]; an observational, cross-sectional, multicenter, international study that involved 3920 patients in 17 countries aimed at evaluating comorbidities in patients with rheumatoid arthritis.
Patient recruitment
Consecutive patients visiting the participating rheumatologists were invited to enroll in the study. Patients were recruited from several rheumatology centers from the 17 countries. All participants received written and verbal information about the
Description of vaccination status by country
The rate of optimal vaccination coverage was low both for PPSV-23 vaccine and influenza vaccine with huge disparities between countries: 636 patients (17.2%) (95%CI: 16.0–18.4) for PPSV-23 vaccination (from 0% in Morocco to 56.5% in France) and 25.3% (95%CI: 23.8–26.5) for influenza vaccination (less than 1% in Morocco and Egypt to 66.2% in Japan). Up to 40% had never received influenza or PPSV-23 vaccines (Table 1, Table 2).
Sociodemographic characteristics and disease characteristics according to the the PPSV-23 vaccine patient profile
In univariate analysis, patients with an oldest age, current NSAIDs,
Discussion
This study aimed to evaluate the use of PPSV-23 and the influenza vaccine in patients with RA from different countries, as well as factors influencing the use of these vaccinations.
These results suggest that the rate of vaccination coverage suggested by current RA treatment guidelines is low for both the influenza vaccine (25%) and PPSV-23 vaccine (17%) with huge disparities between countries.
Several studies have shown that the vaccine coverage of patients with rheumatic diseases worldwide is
Conflict of interest statement
The authors have declared no conflicts of interest.
Acknowledgements
This study has been conducted thanks to an unrestricted grant from Roche. The authors would like to thank the national principal investigators of the COMORA study: Gustavo Casado (Argentina), Josef Smolen (Austria), Bassel Kamal El-Zorkany (Egypt), Martin Soubrier (France), Gerd Burmester (Germany), Peter Balint (Hungary), Carlo Maurizio Montecucco (Italy), Masayoshi Harigai (Japan), Yeong-Wook Song (Korea), Najia Hajjaj-Hassouni (Morocco), Mart van de Laar (the Netherlands), Emilio Martin-Mola
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