Q&A with Leonard Calabrese, DO: Vaccinating in Immunocompromised Patients

Leonard Calabrese, DO

With many patients suffering from rheumatic conditions already immunocompromised because of their condition or possibly the medication they need to treat that condition, vaccines are often a daunting concept for some patients.

Few clinicians have as much perspective on the impact and need for vaccinating among immunocompromised patient populations, including those with rheumatic diseases, as Leonard Calabrese, DO, professor of medicine at the Cleveland Clinic Lerner College of Medicine. The author of hundreds of published works on vaccines, immunocompromised patients, and rheumatology, Calabrese’s wealth of experience provide him with a vantage point few in infectious disease have achieved.

At the 2019 American College of Rheumatology annual meeting in Atlanta, GA, Calabrese led a session discussing the importance of administering shingles, flu, and pneumococcal vaccines to immunocompromised patients. For more on this and how recent trends may have impacted attitudes toward vaccines among patients, MD Magazine® sat down with Calabrese for a Q&A between sessions.

MD Mag: Can you take me through the discussion you led regarding shingles and other vaccines in immunocompromised patients?

Calabrese: It was great to be able to talk about vaccines with rheumatologists. Because we are a very important part of the vaccinology world. The first question is who gives vaccines? The rheumatologists give vaccines or primary care physicians? That needs to be well-orchestrated.

The second question is, how important is it and the whole thrust of this, it's very important. Our patients are immunocompromised, they're more vulnerable to infections, they have more morbidity and mortality from these infections, and vaccines are the best way to prevent these type of complications. The actual nitty gritty of this gets a little bit complicated, but for the three vaccines that we addressed—flu, pneumococcus, and shingles—it's pretty straightforward.

All rheumatology patients need an annual flu vaccine. We use the inactivated vaccines—the quad for younger people, the high dose for people over the age of 65. All of our patients on immunosuppressive are candidates for pneumococcal vaccine and we use the prime boost strategy as outlined by the CDC.

Finally, shingles, a very important infection with a lot of associated morbidity and our patients are particularly vulnerable to because they're on so many medications that lower their immune response. We have two vaccines available: the live vaccine, which we've had for a decade, and the new recombinant antigen mandated vaccine, which is now recommend that all patients over the age of 50 are candidate for this vaccine. We even talked to younger people on higher levels of immunosuppression about doing this.

MD Mag: How do you approach administering vaccines to a patient who may be wary as a result of the anti-vaxx movement?

Calabrese: First, I asked them to help me understand on what basis do you not want the vaccine. Sometimes it's very simple like, "I got the flu from the vaccine before". I can engage on that and generally parse that question. If they're frightened of the vaccine for this reason or that reason, you can try to engage them at a specific level.

Where I think I've been very effective is pointing out to people that you're not only getting vaccinated for yourself, you're getting vaccinated for the people that you love, and the people that are around you. Maybe you don't want the vaccine, but if you get it and it reduces your chance of flu by 20%, it may be your grandchild or your child or your spouse or someone else close to you who when they get the flu might not be so lucky and may be hospitalized or it could even be fatal. So, do it for others. As much as you're doing it for yourself. I think people are mostly highly motivated and they often respond to that.

MD Mag: How are should clinicians be balancing the need to vaccinate patients with the fact that they may be immunocompromised?

Calabrese: We have very good guidelines about how to balance this immunocompromised vaccine question. First of all, for the vast majority of our therapies, inactivated vaccines work quite well with our immunosuppression. Even though the immunogenicity may be attenuated a bit, they are still protective. So, if it comes down to doing it or not doing it, I will do it.

Secondly, we have strategies to try to work around some of the immunosuppression. I said in my talk the other day that it appears that just holding two doses of methotrexate may increase the immunogenicity of flu vaccine by 50%. So, we're learning lessons in this area.

Then finally, we do have some therapies like rituximab, which wipe out B-cells and antibody responses, and we have to develop strategies to work around that giving vaccines at the Nadir of the pharmacodynamic effects or before we give it. Some things can't be avoided, but there's evidence based strategies for dealing with all of this.