What vaccinations can be given to patients about to start infliximab (chimeric monoclonal antibody against tumor necrosis factor-alpha)?

Vaccinations Before Starting Infliximab

All inactivated (killed) vaccines should be administered at least 2 weeks before initiating infliximab, while live attenuated vaccines must be given at least 4 weeks before starting therapy. 1

Inactivated Vaccines (Strongly Recommended)

Priority Vaccinations to Complete Before Infliximab

• Influenza vaccine (inactivated or recombinant) should be given annually, ideally ≥2 weeks before starting infliximab to optimize immune response 2, 3

  • Live attenuated intranasal influenza vaccine is contraindicated 3

• Pneumococcal vaccination is strongly recommended before initiating therapy 1

  • Administer PCV20 (preferred single vaccine) OR PCV15 followed by PPSV23 at least 8 weeks later 1
  • For patients ≥65 years or with chronic conditions like rheumatoid arthritis, this is particularly critical 1

• Hepatitis B vaccine series should be completed before starting infliximab if the patient lacks immunity 1, 4

  • Critical caveat: Response rates drop dramatically once infliximab is started—only 14% achieve protective antibodies if vaccinated after infliximab initiation versus 88% if vaccinated before any immunosuppression 4
  • All patients must be screened for HBsAg and anti-HBc before starting infliximab 2

• Tetanus/diphtheria/pertussis (Tdap) booster should be current 1

• COVID-19 vaccination should be administered at least 2 weeks before starting immunosuppressive therapy 1

• Meningococcal vaccine should be considered, particularly for patients with additional risk factors 1

• Haemophilus influenzae type B (Hib) vaccine may be considered in specific high-risk situations 1

Additional Inactivated Vaccines Based on Risk Factors

• Hepatitis A vaccine for patients at risk (e.g., those receiving frequent blood products) 1

• Human papillomavirus (HPV) vaccine should be given if indicated by age (9-45 years), though immune response may be reduced 1

Live Attenuated Vaccines (Must Be Given Well Before Infliximab)

Timing Requirements for Live Vaccines

Live attenuated vaccines must be held for 1 dosing interval before infliximab and avoided for 4 weeks after administration. 1

• Herpes zoster vaccine (recombinant RZV/Shingrix) is the preferred option for patients ≥50 years 1

  • The recombinant vaccine (RZV) is NOT a live vaccine and can be given safely 1
  • Give 2 doses (2-6 months apart) at least 2 weeks before starting infliximab 1
  • Critical distinction: The older live attenuated zoster vaccine (Zostavax) is contraindicated once biologics are started 1

• Measles, mumps, rubella (MMR) vaccine should be updated if needed, given at least 4 weeks before infliximab 1

• Varicella (chickenpox) vaccine should be administered if the patient lacks immunity, ideally 4 weeks before starting therapy 1

  • Check varicella history or serology; if negative or inconclusive, vaccinate before immunosuppression 1

• Other live vaccines (yellow fever, oral typhoid, oral polio) should be deferred or replaced with inactivated alternatives when available 1

Critical Screening Requirements Before Infliximab

Tuberculosis Screening (Mandatory)

• All patients must undergo TB screening before infliximab initiation, including clinical history, chest radiograph, and tuberculin skin testing or interferon-gamma release assay 2, 3
  • Most TB cases occur within the first 12 weeks of infliximab treatment 2
  • Maintain clinical awareness for TB development for 6 months after stopping infliximab 2

Hepatitis B Screening (Mandatory)

• Screen all patients for HBsAg, anti-HBc, and anti-HBs before starting infliximab 2
  • HBsAg-positive patients have 12-39% risk of HBV reactivation and require antiviral prophylaxis with entecavir or tenofovir starting 2 weeks before infliximab 2

Common Pitfalls to Avoid

• Do not delay vaccination unnecessarily—complete all indicated vaccines before starting infliximab, as immune responses are significantly impaired once therapy begins 4

• Do not give live attenuated vaccines after infliximab has started—this is contraindicated due to risk of vaccine-associated infection 1, 3

• Do not assume household contacts cannot receive live vaccines—most live vaccines (MMR, varicella) can be safely given to household members, though smallpox vaccine cannot 1

• Do not forget to bring pediatric patients up to date with all vaccinations before initiating infliximab, with at least a 6-month waiting period recommended before administering live vaccines to infants exposed in utero 3

• Do not use combination therapy timing for single-agent infliximab—prophylaxis for herpes simplex virus, varicella zoster virus, and Pneumocystis jirovecii is only needed when infliximab is combined with other high-risk agents like alemtuzumab, bortezomib, purine analogues, or high-dose corticosteroids 2