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Shan DM, Chandy RJ, Fultz A, Sanders JW, Feldman SR. Live vaccinations in dermatology for immunosuppressed patients: a narrative review. Arch Dermatol Res 2024; 316:96. [PMID: 38430244 DOI: 10.1007/s00403-024-02827-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/06/2023] [Accepted: 01/25/2024] [Indexed: 03/03/2024]
Abstract
Given the higher susceptibility to infectious disease in patients receiving immunosuppressive therapies for inflammatory dermatologic conditions, immunization is important in this population. While live vaccines protect against life-threatening diseases, they can be harmful in immunosuppressed patients given the risk of replication of the attenuated pathogen and adverse reactions. The utilization of live vaccines in immunosuppressed patients depends on multiple factors such as the vaccine and therapy regimen. To provide an overview of evidence-based recommendations for the use of live vaccines in patients receiving immunosuppressive therapies for dermatological conditions. A literature search of the PubMed database was performed using keywords live vaccine, live-attenuated vaccine, dermatology, immunosuppressed, and immunocompromised, and specific immunosuppressive therapies: corticosteroids, glucocorticoids, methotrexate, azathioprine, cyclosporine, mycophenolate mofetil, biologics. Relevant articles written in English were included. Using these keywords, 125 articles were reviewed, of which 28 were ultimately selected. Recommendations for live vaccines can be determined on a case-by-case basis. Measles, mumps, rubella, varicella (MMRV) vaccines may be safely administered to patients on low-dose immunosuppressive agents while the yellow fever vaccine is typically contraindicated. It may be safe to administer live MMRV boosters to children on immunosuppressive therapies and the live herpes zoster vaccine to patients on biologics. Given poor adherence to immunization guidelines in immunosuppressed patients, dermatologists have a critical role in educating patients and general practitioners regarding live vaccines. By reviewing a patient's vaccination history and following immunization guidelines prior to initiating immunosuppressive therapies, physicians can mitigate morbidity and mortality from vaccine-preventable diseases.
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Affiliation(s)
- Divya M Shan
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Rithi J Chandy
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrew Fultz
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - John W Sanders
- Department of Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Dermatology, University of Southern Denmark, Odense, Denmark
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Shapiro Ben David S, Shamai-Lubovitz O, Mourad V, Goren I, Cohen Iunger E, Alcalay T, Irony A, Greenfeld S, Adler L, Cahan A. A Nationwide Digital Multidisciplinary Intervention Aimed at Promoting Pneumococcal Vaccination in Immunocompromised Patients. Vaccines (Basel) 2023; 11:1355. [PMID: 37631923 PMCID: PMC10458143 DOI: 10.3390/vaccines11081355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/29/2023] Open
Abstract
Immunocompromised patients (IPs) are at high risk for infections, some of which are vaccine-preventable. The Israeli Ministry of Health recommends pneumococcal conjugate vaccine 13 (PCV13) and pneumococcal polysaccharide vaccine 23 (PPSV23) for IP, but vaccine coverage is suboptimal. We assessed the project's effectiveness in improving the pneumococcal vaccination rate among IP. An automated population-based registry of IP was developed and validated at Maccabi Healthcare Services, an Israeli health maintenance organization serving over 2.6 million members. Included were transplant recipients, patients with asplenia, HIV or advanced kidney disease; or those receiving immunosuppressive therapy. A personalized electronic medical record alert was activated reminding clinicians to consider vaccination during IP encounters. Later, IP were invited to get vaccinated via their electronic patient health record. Pre- and post-intervention vaccination rates were compared. Between October 2019 and October 2021, overall PCV13 vaccination rates among 32,637 IP went up from 11.9% (n = 3882) to 52% (n = 16,955) (p < 0.0001). The PPSV23 vaccination rate went up from 39.4% (12,857) to 57.1% (18,652) (p < 0.0001). In conclusion, implementation of targeted automated patient- and clinician-facing alerts, a remarkable increase in pneumococcal vaccine uptake was observed among IP. The outlined approach may be applied to increase vaccination uptake in large health organizations.
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Affiliation(s)
- Shirley Shapiro Ben David
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel (A.I.); (L.A.)
- Tel Aviv School of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
| | - Orna Shamai-Lubovitz
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel (A.I.); (L.A.)
| | - Vered Mourad
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel (A.I.); (L.A.)
| | - Iris Goren
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel (A.I.); (L.A.)
| | - Erica Cohen Iunger
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel (A.I.); (L.A.)
| | - Tamar Alcalay
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel (A.I.); (L.A.)
| | - Angela Irony
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel (A.I.); (L.A.)
| | - Shira Greenfeld
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel (A.I.); (L.A.)
| | - Limor Adler
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel (A.I.); (L.A.)
- Tel Aviv School of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
| | - Amos Cahan
- Infectious Diseases Unit, Samson Assuta Ashdod University Hospital, Ashdod 774762, Israel;
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Shapiro Ben David S, Goren I, Mourad V, Cahan A. Vaccination Coverage among Immunocompromised Patients in a Large Health Maintenance Organization: Findings from a Novel Computerized Registry. Vaccines (Basel) 2022; 10:vaccines10101654. [PMID: 36298519 PMCID: PMC9612260 DOI: 10.3390/vaccines10101654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
Immune-compromised patients (IPs) are at high risk for infections, some of which are preventable by vaccines. Specific vaccines are recommended for IP; however, the vaccination rate is suboptimal. The aim of this study is to describe the development of an IP registry and to assess vaccination rates in this population. A population-based registry of IPs was developed using an automated extraction of patient electronic health-record data in Maccabi Healthcare Services (MHS), an Israeli health maintenance organization serving over 2.4 million members. Included in the registry were patients receiving immunosuppressive therapy (IT); patients living with HIV (PLWH); solid organ and bone marrow transplant recipients (TR); patients with advanced kidney disease (AKD), and asplenic patients. We evaluated the full schedule for each vaccine's uptake rates for influenza, pneumococcal, meningococcal, and hepatitis B. On 1 October 2019, 32,637 adult immune-compromised patients were identified by the registry. Of them, 1647 were PLWH; 2354 were asplenic; 5317 had AKD; 23,216 were on IT; and 1824 were TR. Their mean age was 57 and 52.4% were females. The crude rate of immune compromise among adult MHS members was 2%. Vaccine coverage rate was overall low for PCV13, with only 11.9% of all IPs in the registry having received one dose. Influenza and PPV23 vaccination rates were higher (45% and 39.4%, respectively). Only 5.3% of all IPs received all three vaccines. Overall, low vaccination coverage was found among IPs. Our registry can serve to identify target-patient populations for interventions and monitor their effectiveness.
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Affiliation(s)
- Shirley Shapiro Ben David
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: ; Tel.: +972-37952830
| | - Iris Goren
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
| | - Vered Mourad
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
| | - Amos Cahan
- Infectious Diseases Unit, Samson Assuta Ashdod University Hospital, Ashdod 7747629, Israel
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Abstract
Vaccinations are among the most successful prophylactic measures in medicine. As they are applied to healthy subjects, regulatory steps before licensing of any vaccination are strictly based on clinically controlled studies as well as on registry data in the further course. The probability and relevance of adverse reactions to vaccinations have to be weighed against any harm through the respective natural infection as well as the vaccination-induced protection against infections. Intolerance reactions to vaccinations are far more suspected than proven and altogether rare. Among these, specific dermatoses like psoriasis, atopic dermatitis and lichen planus are found as well as allergic reactions and a number of more nonspecific skin symptoms. Apart from provocation or exacerbation of an underlying dermatological disease, various intolerance reactions may be encountered which are classically allergologic or anaphylactoid. People with chronic dermatoses, especially those on immunosuppressive and immunomodulatory therapy, should have all recommended standard vaccinations. Vaccinations should not be administered during acute skin manifestations and relevant comedication-especially if immunomodulatory or immunosuppressive-has be taken into account in the decision to vaccinate and to define the time point of any vaccination. Inactivated vaccines may be administered even during ongoing immunosuppressive therapy, but may result in decreased immunological reactions and protection to infection. Live vaccines should be avoided.
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Affiliation(s)
- M Sticherling
- Psoriasiszentrum, Deutsches Zentrum Immuntherapie, Hautklinik Universitätsklinikum Erlangen, Ulmenweg 18, 91045, Erlangen, Deutschland.
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Determinants of Vaccination Uptake in Risk Populations: A Comprehensive Literature Review. Vaccines (Basel) 2020; 8:vaccines8030480. [PMID: 32867126 PMCID: PMC7563537 DOI: 10.3390/vaccines8030480] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/13/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022] Open
Abstract
Vaccination uptake has decreased globally in recent years, with a subsequent rise of vaccine-preventable diseases. Travellers, immunocompromised patients (ICP), and healthcare workers (HCW) are groups at increased risk for (severe) infectious diseases due to their behaviour, health, or occupation, respectively. While targeted vaccination guidelines are available, vaccination uptake seems low. In this review, we give a comprehensive overview of determinants-based on the integrated change model-predicting vaccination uptake in these groups. In travellers, low perceived risk of infection and low awareness of vaccination recommendations contributed to low uptake. Additionally, ICP were often unaware of the recommended vaccinations. A physician's recommendation is strongly correlated with higher uptake. Furthermore, ICP appeared to be mainly concerned about the risks of vaccination and fear of deterioration of their underlying disease. For HCW, perceived risk of (the severity of) infection for themselves and for their patients together with perceived benefits of vaccination contribute most to their vaccination behaviour. As the determinants that affect uptake are numerous and diverse, we argue that future studies and interventions should be based on multifactorial health behaviour models, especially for travellers and ICP as only a limited number of such studies is available yet.
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Ziade N, Khoury B, Zoghbi M, Merheb G, Abi Karam G, Mroue’ K, Messayke J. Prevalence and pattern of COMOrbidities in chronic Rheumatic and musculoskeletal Diseases: results of the COMORD study. BMC Rheumatol 2018. [DOI: 10.1186/s41927-018-0025-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Gurvits GE, Lan G, Tan A, Weissman A. Vaccination practices in patients with inflammatory bowel disease among general internal medicine physicians in the USA. Postgrad Med J 2016; 93:333-337. [PMID: 27733673 DOI: 10.1136/postgradmedj-2016-134266] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/13/2016] [Accepted: 09/21/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Increasing prevalence of inflammatory bowel disease (IBD) poses significant challenges to medical community. Preventive medicine, including vaccination against opportunistic infections, is important in decreasing morbidity and mortality in patients with IBD. We conduct first study to evaluate general awareness and adherence to immunisation guidelines by primary care physicians in the USA. METHODS We administered an electronic questionnaire to the research panel of the American College of Physicians (ACP) assessing current vaccination practices, barriers to vaccination and provider responsibility for administering vaccinations and compared responses with the European Crohn's and Colitis Organization consensus guidelines and expert opinion from the USA. RESULTS All of surveyed physicians (276) had experience with patients with IBD and spent majority of their time in direct patient care. 49% of physicians took immunisation history frequently or always, and 76% reported never or rarely checking immunisation antibody titres with only 2% doing so routinely. 65% of physicians believed that primary care providers (PCPs) were responsible for determining patient's immunisation. Vaccine administration was felt to be the duty of primary care doctor 80% of the time. 2.5% of physicians correctly recommended vaccinations all the time. Physicians were more likely to recommend vaccination to immunocompetent than immunocompromised patients. Up to 23% of physicians would incorrectly recommend live vaccine to immunocompromised patients with IBD. CONCLUSIONS Current knowledge and degree of comfort among PCPs in the USA in preventing opportunistic infections in IBD population remain low. Management of patients with IBD requires structured approach to their healthcare maintenance in everyday practice, including enhanced educational policy aimed at primary care physicians.
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Affiliation(s)
- Grigoriy E Gurvits
- Division of Gastroenterology, Department of Medicine, New York University School of Medicine/Langone Medical Center, New York, New York, USA
| | - Gloria Lan
- Division of Gastroenterology, Department of Medicine, Beth Israel Medical Center, New York, New York, USA
| | - Amy Tan
- Department of Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Arlene Weissman
- American College of Physicians Research Center, Philadelphia, Pennsylvania, USA
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Moltó A, Etcheto A, van der Heijde D, Landewé R, van den Bosch F, Bautista Molano W, Burgos-Vargas R, Cheung PP, Collantes-Estevez E, Deodhar A, El-Zorkany B, Erdes S, Gu J, Hajjaj-Hassouni N, Kiltz U, Kim TH, Kishimoto M, Luo SF, Machado PM, Maksymowych WP, Maldonado-Cocco J, Marzo-Ortega H, Montecucco CM, Ozgoçmen S, van Gaalen F, Dougados M. Prevalence of comorbidities and evaluation of their screening in spondyloarthritis: results of the international cross-sectional ASAS-COMOSPA study. Ann Rheum Dis 2015; 75:1016-23. [PMID: 26489703 DOI: 10.1136/annrheumdis-2015-208174] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 09/26/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Increased risk of some comorbidities has been reported in spondyloarthritis (SpA). Recommendations for detection/management of some of these comorbidities have been proposed, and it is known that a gap exists between these and their implementation in practice. OBJECTIVE To evaluate (1) the prevalence of comorbidities and risk factors in different countries worldwide, (2) the gap between available recommendations and daily practice for management of these comorbidities and (3) the prevalence of previously unknown risk factors detected as a result of the present initiative. METHODS Cross-sectional international study with 22 participating countries (from four continents), including 3984 patients with SpA according to the rheumatologist. STATISTICAL ANALYSIS The prevalence of comorbidities (cardiovascular, infection, cancer, osteoporosis and gastrointestinal) and risk factors; percentage of patients optimally monitored for comorbidities according to available recommendations and percentage of patients for whom a risk factor was detected due to this study. RESULTS The most frequent comorbidities were osteoporosis (13%) and gastroduodenal ulcer (11%). The most frequent risk factors were hypertension (34%), smoking (29%) and hypercholesterolaemia (27%). Substantial intercountry variability was observed for screening of comorbidities (eg, for LDL cholesterol measurement: from 8% (Taiwan) to 98% (Germany)). Systematic evaluation (eg, blood pressure (BP), cholesterol) during this study unveiled previously unknown risk factors (eg, elevated BP (14%)), emphasising the suboptimal monitoring of comorbidities. CONCLUSIONS A high prevalence of comorbidities in SpA has been shown. Rigorous application of systematic evaluation of comorbidities may permit earlier detection, which may ultimately result in an improved outcome of patients with SpA.
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Affiliation(s)
- Anna Moltó
- Rheumatology B Department, Paris Descartes University, Cochin Hospital, AP-HP, Paris, France INSERM (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - Adrien Etcheto
- Rheumatology B Department, Paris Descartes University, Cochin Hospital, AP-HP, Paris, France INSERM (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | | | - Robert Landewé
- ARC, Amsterdam & Atrium MC Heerlen, Amsterdam, The Netherlands
| | | | | | - Ruben Burgos-Vargas
- Servicio de Reumatologia, Hospital General de México and Universidad Nacional Autonoma de México, México City, Mexico
| | - Peter P Cheung
- Division of Rheumatology, National University Hospital, Singapore, Singapore
| | - Eduardo Collantes-Estevez
- Rheumatology Department, Reina Sofia Hospital; Maimonides Institute for Biomedical Research of Cordoba/University of Cordoba, Cordoba, Spain
| | - Atul Deodhar
- Div Arthritis/Rheumatic Diseases (OPO9), Oregon Health and Science University, Portland, USA
| | | | | | - Jieruo Gu
- Division of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guanzhou, China
| | - Najia Hajjaj-Hassouni
- Department of Rheumatology, Mohamed Vth University, URAC 30, El Ayachi Hospital, Salé, Morocco Faculty of Medicine and Pharmacy, Rabat, Morocco
| | - Uta Kiltz
- Rheumazentrum Ruhrgebiet, Herne, Germany
| | - Tae-Hwan Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | - Mitsumasa Kishimoto
- Immuno-Rheumatology Center, St Luke's International Hospital, St Luke's International University, Tokyo, Japan
| | - Shue-Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital and Chang Gung University, Tao-Yuan, Taiwan
| | - Pedro M Machado
- Department of Rheumatology, University of Coimbra, Coimbra, Portugal University College London, London, UK
| | | | - José Maldonado-Cocco
- Rheumatology Section, Instituto de Rehabilitacion Psicofisica and Argentine Rheumatologic Foundation "Dr Osvaldo Carcia Morteo", Buenos Aires, Argentina
| | - Helena Marzo-Ortega
- NIHR-Leeds Musculoskeletal Biomedical research Unit, Leeds Institute of Molecular Medicina, University of Leeds, Leeds, UK
| | | | - Salih Ozgoçmen
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Erciyes University, Gevher Nesibe Hospital, Kayseri, Turkey
| | - Floris van Gaalen
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maxime Dougados
- Rheumatology B Department, Paris Descartes University, Cochin Hospital, AP-HP, Paris, France INSERM (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
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