What vaccines are recommended for patients with rheumatic heart disease?

Recommended Vaccinations for Patients with Rheumatic Heart Disease

Patients with rheumatic heart disease should receive influenza, pneumococcal, and recombinant varicella-zoster virus vaccinations, with influenza vaccination being strongly recommended annually regardless of immunosuppressive therapy. 1

Core Vaccinations for Rheumatic Heart Disease Patients

Influenza Vaccination

• High-dose or adjuvanted influenza vaccination is conditionally recommended over regular-dose influenza for patients with rheumatic diseases who are ≥65 years or >18 years and <65 years taking immunosuppressive medications 1
• Influenza vaccination should be administered annually and on schedule, even for patients on immunosuppressive therapies including rituximab 1
• Any influenza vaccine is preferred over no vaccine, so standard-dose should be given if high-dose or adjuvanted vaccines are unavailable 1
• Influenza vaccination should be administered even during periods of high disease activity or when patients are on high-dose glucocorticoids (≥20 mg prednisone daily) 1

Pneumococcal Vaccination

• Pneumococcal vaccination is strongly recommended for patients with rheumatic diseases who are <65 years and taking immunosuppressive medications 1
• Current pneumococcal vaccination options include:
  • PCV20 alone, or
  • PCV15 followed by PPSV23 (with an interval of at least 8 weeks between doses) 1, 2
• Patients with rheumatic diseases are at increased risk of pneumococcal infection due to immune dysregulation and immunosuppression 1, 3
• Vaccination coverage against pneumococcus should be prioritized as patients with rheumatic diseases are at higher risk of pulmonary infections 4

Recombinant Varicella-Zoster Virus (VZV) Vaccination

• Recombinant VZV vaccine is strongly recommended for patients with rheumatic diseases >18 years who are taking immunosuppressive medication 1
• Patients with rheumatic diseases have a higher risk of herpes zoster than the general population 1

Medication Considerations for Vaccination

Methotrexate

• Consider holding methotrexate for 2 weeks after influenza vaccination if disease activity allows 1
• For other non-live vaccinations, continue methotrexate 1

Rituximab

• For influenza vaccination: administer on schedule regardless of rituximab timing, but delay any subsequent rituximab dosing for at least 2 weeks after vaccination if disease activity allows 1
• For other non-live vaccinations: defer until the next rituximab administration is due, and delay rituximab for 2 weeks after vaccination 1

Glucocorticoids

• For patients on prednisone ≤10 mg daily: administer any non-live vaccinations 1
• For patients on prednisone >10 mg but <20 mg daily: administer any non-live vaccinations 1
• For patients on prednisone ≥20 mg daily: administer influenza vaccination, but consider deferring other non-live vaccinations until glucocorticoids are tapered to <20 mg daily 1

Other Immunosuppressive Medications

• Continue other immunosuppressive medications around the time of non-live vaccinations 1

Additional Considerations

Disease Activity

• Non-live vaccinations are conditionally recommended regardless of disease activity 1
• Do not delay vaccination due to concerns about disease activity, as the benefits of vaccination typically outweigh risks 1

Live Attenuated Vaccines

• For patients taking immunosuppressive medications, deferring live attenuated vaccines is conditionally recommended 1
• If live vaccines are required, consider holding immunosuppressive medications for an appropriate period before and 4 weeks after vaccination 1

Secondary Prevention of Rheumatic Fever

• Secondary prevention of rheumatic fever with antibiotic prophylaxis is indicated in all patients with rheumatic heart disease 1
• For patients with rheumatic heart disease and residual valvular disease, prophylaxis should continue for at least 10 years or until age 40 (whichever is longer) 1
• Lifelong prophylaxis may be recommended for patients at high risk of group A streptococcus exposure 1

Practical Implementation

• Consider referring patients to a dedicated vaccine unit to improve vaccination coverage 4
• Multiple vaccinations can be administered on the same day rather than on different days 1
• Early screening and vaccination of people at risk for rheumatic heart disease in endemic areas is recommended 5

Remember that vaccination is a critical component of care for patients with rheumatic heart disease, as they are at increased risk for infectious complications due to both their underlying condition and potential immunosuppressive treatments 1.