What is the recommended vaccination schedule to complete before initiating biologic therapy?

Pre-Biologics Vaccination Schedule

Complete all necessary vaccinations at least 4 weeks before initiating biologic therapy, prioritizing inactivated vaccines first, followed by any required live vaccines with appropriate timing. 1

Critical Timing Framework

Inactivated Vaccines (Can be given anytime, ideally before starting biologics)

Administer these vaccines at least 2 weeks before biologic initiation for optimal immune response, though they can be given closer to start date if necessary:

• Influenza (annual, inactivated formulation only—NOT live attenuated nasal spray)
• Pneumococcal vaccination:
  • PCV20 (single dose) OR PCV15 followed by PPSV23 6-12 months later
  • Booster at 5 years 1
• COVID-19 (updated formulation, then 6-monthly boosters once on therapy) 1
• Recombinant zoster vaccine (Shingrix) for patients ≥50 years, or ≥18 years if starting JAK inhibitors 1
• Hepatitis B (if seronegative; check anti-HBs response post-vaccination) 1
• Tetanus/Diphtheria/Pertussis (Tdap) if not up to date
• Meningococcal (if indicated by risk factors)

Live Vaccines (Require 4-week window BEFORE biologics)

Must complete at least 4 weeks before starting biologic therapy to allow adequate immune response establishment 1, 2:

• MMR (measles, mumps, rubella) if not immune
• Varicella (two-dose series) if no chickenpox history AND varicella antibody negative 1
• Yellow fever (if travel indicated)
• Live zoster vaccine (Zostavax) - though recombinant Shingrix is preferred

Contraindicated Live Vaccines During Immunosuppression

Live vaccines are absolutely contraindicated once on biologics or other immunosuppressive therapy including 1:

• Corticosteroids ≥20 mg/day prednisolone equivalent for ≥2 weeks
• Purine analogues, methotrexate
• All biologic and advanced therapies

Live vaccines to avoid: BCG, oral influenza, oral polio, rotavirus, oral typhoid Ty21a, varicella zoster, yellow fever, live shingles (Zostavax).

Pre-Treatment Screening Requirements

Before vaccination and biologic initiation, screen for 2:

1. Tuberculosis: Interferon-gamma release assay (IGRA) + chest X-ray

   • If latent TB positive: Complete at least 2 months of treatment (3 months isoniazid/rifampicin or 6 months isoniazid) before starting biologics 2

2. Hepatitis B: Surface antigen and core antibody

   • Vaccinate if seronegative 1, 2

3. Hepatitis C: IgG antibody 2

4. HIV: HIV-1/HIV-2 antibodies and HIV-1 antigen 2

5. Varicella immunity: History or serology if considering vaccination 1

Common Pitfalls to Avoid

• Do NOT give live attenuated nasal influenza vaccine—only injectable inactivated formulation 1
• Do NOT delay urgent biologic therapy for non-critical vaccinations if patient has active severe disease with risk of irreversible damage 3
• Do NOT assume childhood vaccination provides lifelong immunity—verify varicella and measles immunity in adults
• Do NOT forget to check hepatitis B response post-vaccination, as immunosuppression may impair response 1
• If the 4-week window for live vaccines cannot be achieved without delaying critical therapy, prioritize disease control and counsel patients on post-exposure prophylaxis strategies (e.g., aciclovir for varicella exposure) 1

Special Considerations

If biologics must be started urgently: Inactivated vaccines can still be given, though response may be suboptimal. Live vaccines become contraindicated once therapy begins and must be avoided for at least 3 months after stopping biologics 1, 4, 1.

For patients already on corticosteroids: If taking <20 mg/day prednisolone, inactivated vaccines can proceed. Live vaccines require tapering below this threshold 1.

Cancer patients: If receiving cytotoxic chemotherapy, ideally vaccinate at least 2 weeks before starting, or between chemotherapy cycles if already initiated 4.