Measles outbreaks should prompt rheumatologists to confirm, discuss vaccination

Cassandra Calabrese

CLEVELAND — With measles reappearing in patient populations across the country, it is now more important than ever for rheumatologists to discuss and offer vaccines during every clinical encounter, according to Cassandra Calabrese, DO, of the Cleveland Clinic.

“I know, like me, you are getting questions from patients regarding whether they should get their titers checked, or if they need a booster vaccine,” Calabrese told attendees at the Biologic Therapies Summit. “With the unfortunate and disappointing current epidemic of measles this year, the country has seen the highest number of measles cases since 1994, starting with a handful of cases in January to almost 900 cases now in the United States as of a few days ago.”

Regarding the measles-mumps-rubella (MMR) vaccine, Calabrese echoed the CDC recommendations that adults who lack evidence of immunity should receive at least one dose of MMR. Acceptable proof of adequate vaccination include documentation of at least one dose of measles-containing vaccine, administered on or after the patient’s first birthday for pre-school-age children and adults not at high risk, and at least two doses among college students, health care workers, international travelers and other high-risk populations.

Other acceptable forms of documented immunity include laboratory evidence, a laboratory confirmation of previous measles and birth prior to 1957.

“If your patients are unsure whether or not they have immunity against measles, encourage them to find their vaccine records, and if they can’t or don’t know, to check their titers,” Calabrese said. “Certainly, it would be a challenge if someone is high-risk and needs a vaccine and there is a live vaccine. I think you would weigh the risks and benefits depending on where they live, their activities and their risk regarding whether or not you would withhold their biologic and give them MMR.”

Regarding vaccinations among patients receiving biologics, Calabrese stated rheumatologists should note that tofacitinib (Xeljanz, Pfizer) has been associated with decreased efficacy for the pneumococcal polysaccharide vaccine, but not with the influenza vaccine. In addition, the best time to vaccinate would be prior to administering methotrexate and tofacitinib, and before biologics, particularly rituximab (Rituxan, Genentech), which is associated with markedly reduced vaccine efficacy.

“However, if you don’t have the luxury of vaccinating before rituximab, remember that some protection is better than no protection,” Calabrese added.

For live vaccines, rheumatologists should cease biologics for at least four weeks, and then restart the treatment regimen two to four weeks later, she said.

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Calabrese also noted that rheumatologists should confirm that “each and every single one” of their patients are receiving an influenza vaccine every year. In addition, the pneumococcal vaccine is universally recommended in all immunocompromised patients, and rheumatologists should administer the PCV13 (Prevnar13, Pfizer) first, if possible, she said.

“Barriers to vaccine uptake sometimes include the vaccines not being stocked or covered, or the patient does not want it, but also communication issues between specialties,” Calabrese said. “We think the primary care doctor is taking care of these, while they think we are. What is the solution? I don’t think there is one answer, and lots of things have been tried, including best practice alerts, standing orders, patient outreach and others.”

“However, adult vaccination rates continue to be abysmal,” she added. “No one practice works best, and perhaps a combination would work best, but we have a lot of work to do in making sure our patients are adequately vaccinated.” – by Jason Laday

Reference:
Calabrese C. Vaccines and IMIDs – sorting out the footnotes. Presented at: Biologic Therapies Summit VIII; May 16-17, 2019; Cleveland, Ohio.

Disclosure: Calabrese reports no relevant financial disclosures.