By: Dr. Mark Matsos
Wednesday, November 10, 2021
COVID Vaccinations and Youth Living with Rheumatic Disease
The COVID-19 pandemic has significantly altered the lives of all Canadians. For adolescent and young adult patients living with autoimmune rheumatic disease, these changes have been particularly profound. Having to navigate the ever-changing guidance around best public health practices as part of a “high risk” population, while simultaneously adjusting to new social routines, unplanned changes to school schedules and post-secondary studies, loss of extra-curricular activities and job opportunities has significantly modified the near-term future for many adolescents and young adults.
Despite these challenges, as we approach the end of 2021, we can finally see some light at the end of the tunnel. We emerge from a fourth COVID wave that has been muted by ongoing public health measures and of course by the remarkable development, approval and deployment of COVID vaccines in an unprecedented manner across Canada.
While safe and effective, vaccine uptake in younger populations (particularly young adults aged 18-29) is lagging behind vaccination rates in older populations. Typically, youth are felt to be less at risk of significant complications from infection, however, unvaccinated young adults are increasingly at risk of hospitalization due to COVID-19. In particular, this has serious implications for those young adults living with rheumatic disease (especially those treated with immunosuppression) who may have delayed or avoided vaccination because of concerns or doubts about the necessity or safety of COVID vaccination.
Conversations around COVID vaccines have become a regular part of the time I spend in the clinic (or virtually over video) with my young adult patients with Juvenile Idiopathic Arthritis (JIA) or Systemic Lupus Erythematosus (SLE) over the last several months. I thought I would share some general considerations for anyone still sitting on the fence or with ongoing reservations about the importance of vaccination.
Patients living with autoimmune rheumatic disease (like JIA and SLE) are at higher risk of hospitalization and worse outcomes compared to the general population should they contract COVID-19. Broadly speaking, vaccinations have been found to be safe and effective in these populations (e.g. influenza) and why it continues to be a strong recommendation that patients with autoimmune illness make every effort to be vaccinated.
mRNA vaccines (Pfizer and Moderna) are recommended over any of the single dose vaccines for COVID protection. For our patients on immunosuppressive medications, we have evidence that two treatments of the mRNA vaccines may not be sufficient to boost immunity to levels seen in healthy populations. For this reason it is likely most patients on immunosuppression will require a third or “booster” vaccination for adequate protection. Booster vaccines are currently available for patients in many provinces - in Ontario, if you have already received two COVID vaccines, with the second vaccine having taken place more than two months ago, booster vaccine is available to you now with proof of immunosuppressive medication management.
Illness and medications do not restrict one from receiving COVID vaccination. There is a small theoretical risk of flare following vaccination, however, overall the benefits of vaccines are felt to outweigh any low risk. We now have evidence from studies of JIA and SLE patients that in the vast majority of patients, these vaccines are well tolerated.
In one small study evaluating the tolerance of COVID vaccination in patients with JIA and on biologic treatment, all participants tolerated the vaccine with infrequent reactions which -- if they occurred -- followed the second dose of the vaccination. At the 3-month follow-up post vaccination, there were no significant changes in clinical disease activity, markers of disease activity on blood work (CRP, ESR) or white blood cell count. Similarly, in a study of patients with SLE, the risk of flare was less than 3% post vaccination, with the majority of flares characterized as mild and not requiring any change in treatment or hospitalization.
If you do choose vaccination, remember to check with your medical team about the need to possibly hold your medications for a short period of time to improve response to the vaccines (e.g. current recommendations suggest holding Methotrexate (MTX) for one week after each of the mRNA vaccines in patients with well controlled disease).
I remind all patients that despite vaccination status, it is important to continue to follow all public health guidelines regarding other preventative measures. Household members and other frequent close contacts of patients with rheumatologic illness also have an important role to play and should also undergo vaccination to further protect their loved ones.
I will continue to be a strong advocate for COVID vaccination in all my patients and particularly in those I treat with immunosuppressive therapies. Our best chance at returning our lives to a “new normal” with fewer restrictions is critically dependent on the success of our vaccination campaign - I hope you will do your part.
Curits JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, et al. American College of Rheumatology Guidance for COVID-19 Vaccination in Patients with Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol 2021. https://onlinelibrary.wiley.com/doi/10.1002/art.41928
Dimopoulou D, Spyridis N, Vartzelis G, Tsolia MN, Maritsi DN. Safety and tolerability of the COVID-19 mRNA-vaccine in adolescents with juvenile idiopathic arthritis on treatment with TNF-inhibitors. Letter. Arthritis Rheumatol. Published online September 7, 2021. doi:10.1002/art.41977
Felton R, Kawka L, Dubois M, Ugarte-Gil M, Fuentes-Silva Y, Piga M. Arnaud L. Tolerance of COVID-19 vaccination in patients with systemic lupus erythematous: the international VACOLUP study. Lancet Rheumatology 2021. https://doi.org/10.1016S2665-9913(21)00221-6
Public Health Ontario, 2021 Ontario COVID-19 Data Tool, November 8, 2021 <publichealthontario.ca>