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2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases
  1. Victoria Furer1,2,
  2. Christien Rondaan3,4,
  3. Marloes W Heijstek5,
  4. Nancy Agmon-Levin2,6,
  5. Sander van Assen7,
  6. Marc Bijl8,
  7. Ferry C Breedveld9,
  8. Raffaele D'Amelio10,
  9. Maxime Dougados11,
  10. Meliha Crnkic Kapetanovic12,
  11. Jacob M van Laar13,
  12. A de Thurah14,
  13. Robert BM Landewé15,16,
  14. Anna Molto11,
  15. Ulf Müller-Ladner17,
  16. Karen Schreiber18,19,
  17. Leo Smolar20,
  18. Jim Walker21,
  19. Klaus Warnatz22,
  20. Nico M Wulffraat23,
  21. Ori Elkayam1,2
  1. 1 Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
  2. 2 Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
  3. 3 Medical Microbiology and Infection Prevention, University Medical Centre Groningen, Groningen, The Netherlands
  4. 4 Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, The Netherlands
  5. 5 Internal Medicine and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
  6. 6 Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel
  7. 7 Department of Internal Medicine (Infectious Diseases), Treant Care Group, Hoogeveen, The Netherlands
  8. 8 Rheumatology and Clinical Immunology, Martini Hospital Groningen, Groningen, The Netherlands
  9. 9 Leiden University Medical Center, Leiden, The Netherlands
  10. 10 Dipartimento di Medicina Clinica e Molecolare, Sapienza Università di Roma, Rome, Italy
  11. 11 Hopital Cochin, Rheumatology, Université Paris Descartes, Paris, France
  12. 12 Section of Rheumatology, Department of Clinical Sciences Lund, Lund, Sweden
  13. 13 Rheumatology & Clinical Immunology, University Medical Centre Utrecht and Utrecht University, Utrecht, The Netherlands
  14. 14 Rheumatology, Aarhus University Hospital, Aarhus, Denmark
  15. 15 Amsterdam Rheumatology Center, AMC, Amsterdam, The Netherlands
  16. 16 Rheumatology, Zuyderland MC, Heerlen, The Netherlands
  17. 17 Rheumatology and Clinical Immunology, Giessen University, Bad Nauheim, Germany
  18. 18 Department of Thrombosis and Haemophilia, Guy's and St Thomas' Hospital, London, UK
  19. 19 Department of Rheumatology, King Christian X's Hospital for Rheumatology Diseases, Graasten, Denmark
  20. 20 Patient Research Partner, Tel Aviv, Israel
  21. 21 Patient Research Partner, Elgin, UK
  22. 22 Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany
  23. 23 Department of Pediatrics Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
  1. Correspondence to Victoria Furer, Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv 62431, Israel; furer.rheum{at}


To update the European League Against Rheumatism (EULAR) recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD) published in 2011. Four systematic literature reviews were performed regarding the incidence/prevalence of vaccine-preventable infections among patients with AIIRD; efficacy, immunogenicity and safety of vaccines; effect of anti-rheumatic drugs on the response to vaccines; effect of vaccination of household of AIIRDs patients. Subsequently, recommendations were formulated based on the evidence and expert opinion. The updated recommendations comprise six overarching principles and nine recommendations. The former address the need for an annual vaccination status assessment, shared decision-making and timing of vaccination, favouring vaccination during quiescent disease, preferably prior to the initiation of immunosuppression. Non-live vaccines can be safely provided to AIIRD patients regardless of underlying therapy, whereas live-attenuated vaccines may be considered with caution. Influenza and pneumococcal vaccination should be strongly considered for the majority of patients with AIIRD. Tetanus toxoid and human papilloma virus vaccination should be provided to AIIRD patients as recommended for the general population. Hepatitis A, hepatitis B and herpes zoster vaccination should be administered to AIIRD patients at risk. Immunocompetent household members of patients with AIIRD should receive vaccines according to national guidelines, except for the oral poliomyelitis vaccine. Live-attenuated vaccines should be avoided during the first 6 months of life in newborns of mothers treated with biologics during the second half of pregnancy. These 2019 EULAR recommendations provide an up-to-date guidance on the management of vaccinations in patients with AIIRD.

  • vaccination
  • infections
  • autoimmune diseases
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  • Handling editor Josef S Smolen

  • VF and CR contributed equally.

  • Correction notice This article has been corrected since it published Online First. Author names have been amended, affiliations updated and the equal contribution statement also added.

  • Contributors All listed authors of the manuscript are the members of the EULAR assigned task force dedicated to the update of recommendations of vaccination in adult patients with AIIRD. All authors contributed to the formulation of the recommendations. In details, the steering committee of the task force that included convenor (OE), co-convenor (ULM), an immunologist (MB), a specialist in infectious disease (SvA) and methodologists (JL and RL) defined the research questions for the systematic literature reviews (SLRs), that were performed by three fellows (VF, CR, MH), under supervision of the experts in rheumatic diseases (MB) and infectious diseases (SvA). The manuscript was drafted by VF and revised by all task members.

  • Funding This study was funded by European League Against Rheumatism.

  • Patient consent for publication Not required

  • Provenance and peer review Not commissioned; externally peer reviewed.

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