Patient Education Needed to Boost Vaccination Rates Among Those With Psoriasis PsA
A study of the live herpes zoster vaccine in patients with psoriasis is just one of many in recent years to demonstrate the safety and effectiveness of vaccines in this patient population, yet vaccination rates in this group remain low.
This is why dermatologists, who many psoriasis patients see more frequently than other health care providers, need to educate their patients about vaccines, according to Joel M. Gelfand, MD, MSCE, professor of dermatology and epidemiology at University of Pennsylvania Perelman School of Medicine and director of the Perelman School’s Psoriasis and Phototherapy Treatment Center. Gelfand shared some insight on vaccination rates for patients with psoriasis or psoriatic arthritis and some tips for emphasizing their importance with Healio Psoriatic Disease.
Q: Why are vaccination rates lower for patients with psoriasis and/or psoriatic arthritis?
Gelfand: My group did a study on this. Megan Noe was the lead author on it, and we looked at vaccination rates with influenza — for example, between people with psoriasis, hypertension and rheumatoid arthritis. Where we saw some of the biggest gaps were in younger individuals. In particular, they tend to be undervaccinated for the flu. We do not really know why. Some of it may be because patients who have psoriasis, their main physician may be a dermatologist and they may not be seeing their primary care doctor, who traditionally is the one who would counsel them and give them vaccines. I think that is probably a big part of what is going on.
Q: Why are some patients with psoriasis or PsA at a higher risk for shingles?
Gelfand: The strongest data seem to suggest that when we see a relationship between psoriasis and shingles, it is high among people on certain immunomodulatory therapies. To date, what has probably been best demonstrated is a risk with TNF inhibitors. And even in that setting, the risk seems to be most significant for those who are on combination therapies — they are getting a TNF inhibitor plus methotrexate and maybe prednisone.
Putting that aside, we know that many illnesses are vaccine preventable. If a patient develops shingles, for example, that is a miserable thing to have, and if you have psoriasis, what makes it even worse is that people often develop psoriasis in their shingles, and then they are stuck with not only having shingles, but then when it heals they are left with psoriasis now affecting where they developed shingles.
That is part of the reason why it is important to educate people with psoriasis about being up to date with their vaccine schedules. If you have a bad flu, that is going to interfere with your ability to take your psoriasis treatments, for example. You are going to have to stop your biologics, and your psoriasis may flare, or viral infections in general tend to flare psoriasis. So generally speaking, the goal is to use an age-appropriate vaccine strategy because patients with psoriasis seem to be more susceptible to having bad outcomes from infections, having complications from psoriasis from infections, things of that nature. So, it is an opportunity to do some prevention for them.
Q: What needs to be considered in deciding whether a patient should receive a live vaccine or a recombinant vaccine?
Gelfand: It depends on the type of vaccine we are talking about. Most vaccines in the United States are killed vaccines. There are exceptions. So, for example, one of the older shingles vaccines was a live vaccine, and it was not particularly effective. The newer shingles vaccine, Shingrix (recombinant zoster vaccine, adjuvanted, GlaxoSmithKline), is a killed vaccine, and therefore one could administer it to a patient who is on an immunomodulating therapy without having to worry if they are going to get a vaccine-related illness. They are not going to get shingles from a killed vaccine, although they could get shingles or chickenpox from a live chickenpox vaccine.
Similarly, the inhaled flu vaccine is a live vaccine. Patients who are on immune modulators do not get the inhaled flu vaccine; they should get the shot, which is killed.
Q: You mentioned making sure that the vaccine is age appropriate. What role does age play in recommending vaccines?
Gelfand: Age relates to risk for an outcome and protection as well. Let’s take the HPV vaccine, which is commonly recommended for people starting at age 11 years. And now the recommendations go up to age 45 years. Here is an example in which you could prevent cervical cancer, head and neck cancer, and anal cancer related to HPV infection. The goal of giving it to people in childhood is they have a low likelihood of having already contracted the HPV infection before they become sexually active. Once someone is sexually active and has multiple partners, the likelihood of having HPV is very high. In the average adult, the prevalence of HPV genital wart virus is 60%. This an example in which you want to give the vaccine before someone contracts the disease, and that is why the emphasis is on younger people. But still, the recommendations go up to people who are in their mid-40s. I have lots of patients in my practice who are in their young 20s and never had the HPV vaccine, and we encourage them to get it because we do not want them getting cervical cancer or head and neck cancer or other problems.
Other vaccines relate to the risk for developing outcomes: As we get older, the risk for developing shingles goes up substantially. Your risk of having shingles reactivation of chickenpox when you are 20 years old is much lower than that risk when you are 70 or 80 years old. The cutoff seems to be at age 50, as there is substantial risk reduction when people are 50 or older for getting the shingles vaccine.
Q: Recent National Psoriasis Foundation and American College of Rheumatology guidelines recommend delaying the start of administering a biologic drug while administering live attenuated vaccines. Do you know what is behind that recommendation?
Gelfand: Safety is not established very well in that setting, and the concern is that when you have a live attenuated vaccine that one could then contract the actual illness in the setting of being immunocompromised when you get the vaccine. That is why ideally someone would not be on one of these immune modulators when they are getting this vaccine: to lower their risk for contracting the attenuated version of the disease that we are trying to prevent in the first place.
Q: What are the next steps in studying the use of live vaccines for patients with psoriasis/PsA?
Gelfand: An open question is whether or not a younger person who is on a biologic should get their shingles vaccine earlier. We do not know the answer to that question. If you are 40 years old and you are on a TNF inhibitor and methotrexate, should you get the shingles vaccine? We just do not know the answer to that question or whether it would be clinically useful or not. That is a big gap in our knowledge: Should the recommendations be different if you have psoriasis from the standard recommendations?
Q: Do you have any tips for counseling patients who may be hesitant about vaccines?
Gelfand: Sometimes personal stories are helpful. Also, explain how it relates to their psoriasis.
For example, Ruth Bader Ginsburg: Her mother died of cervical cancer and her sister died of meningitis when Ginsburg was a child. These are both vaccine-preventable illnesses; had she been born in this day and age and had the vaccine, her mother would not have died when she was a child. Most people are fans of Ruth Bader Ginsburg, so that just makes it real to people. That is one way of making people understand the value.
Another is reminding them that it will complicate their course of psoriasis. If they get the flu, their psoriasis is likely to flare. Also, they are going to have to stop their treatment for psoriasis to recover from the flu, and their psoriasis is likely to flare from that. We want to lower their risk for having these problems.
Q: Anything else you would like to add?
Gelfand: In my practice we give the flu shot, and many of my parents who we have been seeing for years come to me to get their flu shot. We hope dermatologists get engaged in offering vaccines to their patients. We are part of the public health workforce. Our patients will benefit from these vaccines, and they appreciate the convenience of having it offered when they are seeing us.
Noe MH, et al. J Invest Dermatol. 2019;doi:10.1016/j.jid.2018.09.012.
For more information:
Joel M. Gelfand, MD, MSCE, can be reached at Joel.Gelfand@pennmedicine.upenn.edu.