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Logo of annrheumdAnnals of the Rheumatic DiseasesCurrent TOCInstructions for authors
Ann Rheum Dis. Jun 2007; 66(6): 837–838.
PMCID: PMC1954646

Audit on the uptake of influenza and pneumococcal vaccination in patients with rheumatoid arthritis

According to the Department of Health guidelines in the UK, patients who are immunosuppressed should be vaccinated against influenza and pneumococcal infection.1 There are now convincing data regarding the efficacy of vaccination and use of disease‐modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA).2,3,4,5 There is evidence from other countries that the uptake of vaccination is suboptimal, especially in those aged <65 years.6

We undertook a study in patients attending our clinics to establish (1) vaccination uptake in our patients who are immunosuppressed, and (2) the reasons if patients had not received the influenza or pneumococcal (pneumovax) vaccination.

We collected data from 155 consecutive patients attending our clinics during March 2006. We enquired about vaccination status during the winter 2005–6 using a questionnaire. We noted whether the patients had received pneumococcal vaccine previously, as this vaccine does not have to be repeated annually. We also noted the diagnosis, current DMARD and glucocorticoid use.

The most common diagnosis was RA (64/155; table 11).). DMARDs used were methotrexate (n = 37), sulfasalazine (n = 29), azathioprine (n = 9), prednisolone (n = 10), mycophenolate (n = 3) and tumour necrosis factor α blockade (n = 10); 57 of 155 (37%) patients were not receiving any DMARD or corticosteroids.

Table thumbnail
Table 1 Patient diagnosis

Twenty eight (43%) patients with RA had received both influenza and pneumococcal vaccination, 24 (38%) had received neither, 12 (19%) had received influenza vaccination alone, and no patient had received pneumococcal vaccination alone. This was independent of DMARD use. Among the 105 patients with RA and/or taking DMARD, 39 (37%) had received both influenza and pneumococcal vaccine, 24 (23%) had received influenza vaccine only, 2 (2%) had received pneumococcal vaccine only, and 40 (38%) neither.

Influenza vaccination was not received by 24 of 64 patients with RA, the principal reasons being not been offered (5/24), not being old enough (2/24) and for no reason (7/24). Five patients declined vaccination. Pneumococcal vaccination was not received by 36 of 64 patients with RA, because of similar reasons as for not receiving influenza vaccination, except that 5 of 36 patients were not aware of the need for vaccination. Although not specified, the reason for not offering vaccination to these patients might have been their age. There was no single major reason for patients declining vaccination, but offered reasons included fear of vaccination, previous reaction, thought it unnecessary, and this has been noted before.5

The vaccination rate in this cohort of patients was suboptimal, at 37%. This figure is only marginally better than those reported from other countries (20–35%).6 The main reason is that patients were not offered vaccination. In the UK, vaccination is routinely offered to people aged >65 years and to those who are immunocompromised. There is a national annual campaign for influenza vaccination every autumn that is coordinated through the computerised age registers maintained in primary care centres. Patients aged <65 years may not be automatically called for vaccination. It is preferable for patients to receive pneumococcal vaccination before starting immunosuppressive therapy, as there is evidence that some patients have a suboptimal response while taking methotrexate.3 This, however, may not always be practicable.

This small audit conducted in a routine rheumatology clinic in the UK suggests that the present strategies for vaccinating patients who are immunocompromised, especially those aged <65 years, is inadequate. We recommend that primary care physicians be educated about the need for vaccination in patients who are taking DMARDs and corticosteroids. Patients should also be educated on the need for vaccination.


DMARD - disease‐modifying antirheumatic drug

RA - rheumatoid arthritis


Competing interests: None.


1. PL CMO (2006) 3. The influenza immunisation programme 2006/2007. http://dh.gov.uk (accessed 12 Mar 2007)
2. Kapetanovic M C, Saxne T, Nilsson J ‐ A, Geborek P. Influenza vaccination as model for testing immune modulation of anti‐TNF and methotrexate therapy in RA patients. Rheumatology 2007. 46608–611.611 [PubMed]
3. Kapetanovic M C, Saxne T T, Sjoholm A. Influence of methotrexate, TNF blockers and prednisolone on antibody responses to pneumococcal vaccine in patients with RA. Rheumatology 2006. 45106–111.111 [PubMed]
4. Mease P J, Richlin C T, Martin R W, Gottleib A B, Baumgartner S W, Burge D J. et al Pneumococcal vaccine response in psoriatic arthritis patients during treatment with etanercept. J Rheumatol 2004. 311356–1361.1361 [PubMed]
5. Fomin I, Caspi D, Levy D, VarsanO N, Shalev Y, Paran D. et al Vaccination against influenza in rheumatoid arthritis: the effect of disease modifying drugs, including TNF alpha blockers. Ann Rheum Dis 2006. 65191–194.194 [PMC free article] [PubMed]
6. Gluck T. Vaccinate your immunocompromised patients. Rheumatology 2006. 459–10.10 [PubMed]

Articles from Annals of the Rheumatic Diseases are provided here courtesy of BMJ Group
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