Vaccination considerations in autoimmune rheumatic diseases

Patients with autoimmune rheumatic diseases (ARDs) are at increased risk of numerous vaccine-preventable infections owing to a combination of disease-related immune dysregulation, immunosuppressive therapies - including glucocorticoids - and comorbidities. Age-related immunosenescence further increases this susceptibility in older patients. The SARS-CoV-2 (COVID-19) pandemic and measles outbreaks have underscored the importance of optimizing vaccination strategies and improving adherence to recommendations. Nevertheless, coverage for routinely recommended vaccines, including influenza and pneumococcal vaccines, remains suboptimal in this population. Vaccine hesitancy is an important barrier driven by concerns regarding safety, tolerability, disease flares and the potential induction of new autoimmune phenomena. Advanced therapies - including B cell-depleting agents, chimeric antigen receptor T cell therapy and bispecific T cell engagers - can substantially impair vaccine-induced immune responses, highlighting the importance of optimizing vaccination timing in relation to treatment. Although most studies focus on humoral and cellular immune responses, evidence on the long-term durability of vaccine-induced immunity, the need for booster doses and real-world vaccine effectiveness in patients with ARDs remains limited. Ethical considerations are important. Although vaccination in adults is generally not mandatory, improving vaccine uptake reduces the burden of infections in patients with ARDs, contributes to herd immunity and provides indirect protection for other vulnerable populations.