Table 2

Recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases with level of evidence, strength of recommendations and results of Dephi voting per recommendation

Category of evidenceStrength of recommendationMean (SD) level of agreement by Delphi voting (VAS)
RecommendationIncreased incidence of VP infectionEfficacy of vaccinationHarms of vaccination
The vaccination status should be assessed in the initial investigation of patients with AIIRDD9.50 (0.97)
Vaccination in patients with AIIRD should ideally be administered during stable diseaseD8.88 (1.26)
Live attenuated vaccines should be avoided whenever possible in immunosuppressed patients with AIIRDIVD9.25 (1.13)
Vaccination in patients with AIIRD can be administered during the use of DMARDs and TNFα blocking agents, but should ideally be administered before starting B cell-depleting biological therapyIIB9.13 (1.02)
Influenza vaccination should be strongly considered for patients with AIIRDIIIIbIbB–C9.00 (1.10)
23-valent polysaccharide pneumococcal vaccination should be strongly considered for patients with AIIRDIIIIbIbB–C8.19 (1.38)
Patients with AIIRD should receive tetanus toxoid vaccination in accordance with recommendations for the general population. In case of major and/or contaminated wounds in patients who received rituximab within the last 24 weeks, passive immunisation with tetanus immunoglobulin should be administeredIIIIB–D9.19 (1.11)
Herpes zoster vaccination may be considered in patients with AIIRDIIIIVC–D8.00 (1.59)
HPV vaccination should be considered in selected patients with AIIRDIIIC–D8.44 (1.41)
In hyposplenic/asplenic patients with AIIRD, influenza, pneumococcal, Haemophilus influenzae b and meningococcal C vaccinations are recommendedIVD9.50 (0.82)
Hepatitis A and/or B vaccination is only recommended in patients with AIIRD at riskII*III*D9.13 (0.89)
Patients with AIIRD who plan to travel are recommended to receive their vaccinations according to general rules, except for live attenuated vaccines which should be avoided whenever possible in immunosuppressed patients with AIIRDD9.25 (1.24)
BCG vaccination is not recommended in patients with AIIRDIIID9.38 (1.09)
  • * For hepatitis B only

  • AIIRD, autoimmune inflammatory disease; BCG, Bacillus Calmette-Guérin; DMARD, disease-modifying antirheumatic drug; HPV, human papillomavirus; TNF, tumour necrosis factor; VAS, visual analogue scale; VP, vaccine-preventable.