Michael D. Lockshin, MD

A patient with APS recently emailed me with a question about vaccinations for her two small children. Her concern was that her children may be genetically susceptible to having a reaction or could develop an autoimmune condition from their vaccinations. She like the rest of the general public has gotten conflicting information about vaccinations, not only for autoimmune diseases, but other illnesses like Autism as well. And she wanted to know where she could get information about the question of vaccinations and autoimmune diseases. Here is what I wrote her:

There is a Nobel Prize available for the person who can answer your question(s). Current thinking is that lupus (and, by extension, APS) is triggered by a common virus in a susceptible person. The leading suspicious virus is cytomegalovirus (CMV), which causes a mononucleosis-like disease; Epstein-Barr virus (EBV), which causes mononucleosis, is another candidate. There is an extensive medical literature on this topic. John Harley and Judith James, in Oklahoma, have published several papers indicating that the infection likely occurs a decade or more before the disease becomes obvious. You can hunt for these papers at the National Library of Medicine site (PubMed) and search on the terms “Harley J AND lupus” or “lupus AND CMV” or such to find the papers, or, given a day or two, I can compile a list for you.

None of us in my world think of vaccinations as likely virus triggers; on the other hand, if you have no concept of how devastating polio, tetanus, diphtheria, measles, etc. can be (lethal, brain-damaging, permanently disabling) you may underestimate the value of vaccination. If you choose not to vaccinate your children, you rely on “herd immunity”, that is, the luck that others they encounter will be immune and protect them. Loss of herd immunity has resulted in epidemics as recently as this year of these common diseases in fundamentalist communities, Native American communities, and “hippie” colonies in the United States this year, so these diseases are by no means gone.

Bottom line: although your children may have inherited (a degree of) susceptibility from you, they are somewhat protected by their father’s genes; vaccinations are not the things to fear. Rather, common infections, some of which can be prevented by vaccination, are more likely triggers.

Special Report
Michael D. Lockshin, MD

At this time of year, patients with lupus, rheumatoid arthritis, and other autoimmune diseases always ask, “Should I get a flu vaccination?” At this time in our history, many patients are also asking, “Should I get a smallpox vaccination?” These questions are really about three more general questions: 

1. Are patients with autoimmune diseases unusually susceptible to flu or smallpox?
2. Can patients with autoimmune diseases be adequately protected if they do receive a vaccination?
3. Is the vaccine safe, in the sense that it can either cause autoimmune disease to worsen or can cause complications by itself?

The brief answers, which are different depending on the disease and vaccine, are:

1. Patients taking immunosuppressive drugs, including prednisone or other corticosteroids, and those with lung and/or kidney disease, are unusually susceptible to flu.

Although little is known about susceptibility to smallpox, based on what happens with the related varicella virus (which causes chickenpox and shingles), patients on immunosuppressive drugs will likely be at high risk for severe disease if they are exposed to smallpox.

For both diseases, the increased risk includes patients taking: corticosteroids, such as prednisone and methylprednisolone (Medrol); immunosuppressive drugs, such as methotrexate (Rheumatrex, Trexall), azathioprine (Imuran), mycophenolate mofetil (CellCept), cyclophosphamide (Cytoxan), leflunomide (Arava), cyclosporine (Sandimmune, Neoral) and similar drugs; and biologics, such as the TNF-alpha inhibitors infliximab (Remicade) and etanercept (Enbrel) and the IL-1 inhibitor anakinra (Kineret).

2. Flu vaccine successfully protects patients with rheumatic disease, if they are not taking high doses of immunosuppressive drugs.
3. Flu vaccine does not worsen rheumatic disease and is generally well tolerated by rheumatic disease patients.

See the complete article on the Hospital for Special Surgery’s web site