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Infection, Immunisation and Lupus

Neil Snowden, Consultant Rheumatologist,Pennine Acute Hospitals Trust

Infections are a major problem for people with lupus. Many kinds of infection occur more frequently in lupus and, sadly, about one quarter of deaths of people with lupus are due to infections. There is no single reason for this increase in risk. Lupus itself seems to reduce resistance to some infections. Having lung problems or reduced kidney function are also known to make infection more likely. A particularly important factor is that many of the treatments for lupus increase the risk of infection. Lupus is caused by overactivity of the body’s immune system. Most treatments work by dampening down the immune system. This is helpful in treating lupus, but it also reduces the normal function of the immune system- to protect against infection. Drugs commonly used in lupus which reduce the activity of the immune system (these are called immunosuppressants) are listed in table 1. Not all drugs used in lupus seem to increase the risk of infection- hydroxychoroquine, chloroquine and anti-inflammatory drugs seem safe in this regard.

Many kinds of infection seem to be more common in lupus- particularly chest infections and pneumonias. There is evidence that people with severe lupus, particularly those with kidney disease, may be particularly vulnerable to infection with a bacteria called pneumococcus.

 

How can the risk of infection be reduced?

It is important that people with lupus, their carers and  healthcare workers are aware of the increased risk, and that infections are treated promptly when they occur. People with lupus do not, in general, need to take special care to avoid exposure to infection, but some sensible precautions around food hygiene (particularly when travelling) should be taken when taking immunosuppressant drugs. A good source of information about individual drugs are the leaflets produced by Arthritis Research UK. Active lupus increases the risk of infection- but so do immunosuppressant drugs. This means that treatment is a balancing act- taking enough treatment to control the lupus, but keeping the dose of steroids and other drugs controlled, so as to keep the risk of infection to a minimum. However, because of the way these drugs work, this risk cannot be taken away completely. The risks of infection can also be reduced for some infections by immunisation (also known as vaccination).

Immunisation and lupus

Immunisation is a way of boosting resistance to specific infections. There are two kinds: active and passive. Active immunisation is when a killed or weakened form of a bacteria or virus (known as a vaccine) is used to stimulate the body’s immune system to make antibodies which then protect  against further infections with that particular bacteria or virus. This protection is long lasting and can be life-long. Passive immunisation is a more temporary process when antibodies are purified from the blood of people with resistance to a particular infection and given to people at risk. This gives a few weeks of protection from that infection.

Immunisations are used widely at different stages in life-

  • in childhood to give protection against a range of common infections
  • before travelling to countries with a higher risk of infection
  • in people with vulnerability to infection.  This vulnerability is either because they have a high risk of exposure, or because they are at risk of being severely affected by particular infections- usually because of age or underlying medical problems. Many people with lupus fall into this category. Vaccines in routine use in the NHS are listed in table 2.

There are two important questions about vaccines in people with lupus:

1) are they safe?

2) do they work?

Safety

There have been concerns that immunisation might cause lupus to flare, and many years ago immunisation tended to be avoided for this reason. In many ways this is an understandable concern: lupus is a disease where the immune system is overactive, and immunisation aims to stimulate the immune system. Fortunately, immunisation does seem to be safe in lupus, and if flares occur, then these are rare. It should also be noted that infection itself can cause lupus to flare, which is a strong reason to prevent infection.

However, one particular group of vaccines do need to be avoided by people who take immunosuppressant drugs- these are the so-called live vaccines which are made up of weakened forms of the organism causing a disease. In healthy people these cause no disease, but they can cause illness in those with weakened immune systems. A list of live vaccines which are used in the UK is shown in table 3- these should be avoided by people who take the drugs in table 1 (or who have recently taken these drugs).

Do vaccines work to prevent infection in lupus?

In general the answer seems to be-yes, although vaccines seem to produce slightly lower levels of protective antibodies  in lupus compared to healthy people. The level of protection also seems to be reduced in people taking immunosuppressant drugs. Even though lower levels of antibodies are produced, the levels still seem to be high enough to protect against infection. The exception to this is the newer treatment rituximab. Treatment with this drug does seem to stop protective antibodies being produced. In an ideal world, vaccinations would be given before rituximab and other powerful immune suppressing drugs, but since treatments in lupus are sometimes given urgently, this isn’t always possible

Special cases

Influenza

In the UK influenza immunisation is given to vulnerable people each year, targeted against the strains of influenza that are present that year. Everyone over 65 should receive influenza vaccine, and also younger people with a variety of medical conditions, including heart, lung or kidney disease, and people on immune suppressing drugs. Very many people with lupus will fall into one of these drugs, and immunisation is strongly recommended

Pneumococcus

Pneumococcal immunisation is now given routinely in childhood, although this is a recent development- so adults are unlikely to be protected. It is therefore also given to similar groups of people as influenza- and also to people whose spleen (a blood –filtering organ) doesn’t work or has been removed. It is. Again, many people with lupus will fall into these groups. As mentioned earlier, some people with lupus may be particularly vulnerable to this infection, so again immunisation is recommended if you are in one of the vulnerable groups.

Hepatitis B

Hepatitis B immunisation is offered to people at increased risk of exposure to this infection which is carried in blood and other body fluids. For example, most people who work in front-line jobs in the NHS will be required to have this vaccine.  There is perhaps slightly more evidence that Hepatitis B immunisation can cause lupus to flare compared to other vaccines, but overall the benefits of immunisation outweigh the risks.

Travel

Most  immunisations for travel present no problems in lupus- but care should be taken around live vaccines in people on potent immune suppressing drugs. Your doctor or local travel clinic should be able to offer you advice on this, and whether alternatives are available. You may also need to take other precautions, such as tablets to prevent malaria. It should be noted that although hydroxychloroquine and chloroquine were developed as anti-malaria drugs, they will not work to protect against malaria in most parts of the world.

Chicken Pox

Most people will develop chicken pox in early childhood and are protected from further infection. However, chicken pox can be a severe illness in people taking powerful immune suppressing drugs. If you are taking these drugs and become exposed to chicken pox then you need an urgent blood test to measure your resistance to this infection, and if this is low, then you should be offered an injection of protective antibodies. Your GP, local hospital or walk in centre should be able to offer advice.

Conclusions.

People with lupus are at risk from infection- and immunisations are one way of reducing that risk. Immunisations seem to be safe in lupus (although care is needed with live vaccines in people taking many lupus treatments), and seem to work for most people. Keeping up to date with immunisations is therefore recommended- although this is clearly a matter of personal choice. Your GP, hospital doctors, and the NHS Direct service are all good sources of advice.

*          Steriods (for example, Prednisolone)
*          Immunosuppresant drugs
             –        Ciclosporin
             –        Mycophenolate
             –        Azathioprine
             –        Leflunomide
             –        Methotrexate
*        Biologic drugs
             –        Rituximab

Table 1: Drugs used in lupus which reduce the activity of the immune system

2 months:

  • Diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b (Hib, a bacterial infection that can cause severe pneumonia or meningitis in young children) given as a 5-in-1 single jab known as DTaP/IPV/Hib
  • Pneumococcal infection

3 months:

  • 5-in-1, second dose (DTaP/IPV/Hib)
  • Meningitis C

4 months:

  • 5-in-1, third dose (DTaP/IPV/Hib)
  • Pneumococcal infection, second dose
  • Meningitis C, second dose

Around 12 months:

  • Meningitis C, third dose
  • Hib, fourth dose (Hib/MenC given as a single jab)

Around 13 months:

  • MMR (measles, mumps and rubella), given as a single jab
  • Pneumococcal infection, third dose

3 years and 4 months, or soon after:

  • MMR second jab
  • Diphtheria, tetanus, pertussis and polio given as a 4-in-1 pre-school booster

Around 12-13 years:

  • Cervical cancer (HPV) vaccine, which protects against cervical cancer (girls only)

Around 13-18 years:

  • Diphtheria, tetanus and polio booster (Td/IPV), given as a single jab

65 and over:

  • Flu (every year)
  • Pneumococcal

Table 2: A summary of immunisations currently recommended by the NHS

Oral Polio – now rarely used in the UK
Measles, Mumps, Rubella (MMR)
Yellow fever (for travel to certain countries)
Typhoid (for travel to certain countries)
Varicella zoster (Chicken Pox)
BCG (Tuberculosis)

Table 3- Live vaccines used in the UK

Our thanks to Dr Neil Snowden for kindly writing this article following his presentation at the North West Lupus Group AGM.

 

 

 

 

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