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10 Updated immunization guidelines
  1. Nancy Agmon-Levin
  1. Sheba Medical Center, Israel


Vaccination prevents infectious diseases by inducing/enhancing protective immunity, potentially translating into a lower rate of invasive infections and hospital admissions. Patients with autoimmune inflammatory rheumatic diseases (AIIRD), and particularly systemic lupus erythematosus (SLE) are at increased risk of vaccine-preventable infections, attributed to the underlying autoimmune disease, additional comorbidities and immunosuppressive therapies. Yet, this population of patients is generally sub-optimally immunized due to concerns about efficacy, immunogenicity, and safety of vaccines shared both by patients and their treating physicians. In this regard, vaccination may be less efficacious in subgroups of patients with AIIRD, such as SLE and could potentially be associated with temporal (usually mild) exacerbation of the underlying autoimmune disease. Immunization protocols which take into consideration the AIIRD itself, timing of immunization and the number of vaccines doses may enable safe and efficacious immunization.1–6

In recent years updated recommendations for immunization of AIIRD patients were issued. These recommendations comprise several overarching principles as: annual vaccination status assessment, shared decision-making, timing of vaccination (e.g. favoring vaccination during quiescent disease, preferably prior to initiation of immunosuppression), and avoidance of some live-attenuated vaccines both for patients and their household members. Additionally, new data suggest that increasing the doses of vaccine (e.g. anti-COVID vaccines) may overcome lower immunogenicity among SLE and other AIIRD patients.

Herein, an up-to-date guidance for immunization of SLE patients in 2023 will be reviewed.


  1. Furer V, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2020 Jan;79(1):39–52. doi: 10.1136/annrheumdis-2019-215882.

  2. Furer V, et al. Incidence and prevalence of vaccine preventable infections in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD): a systemic literature review informing the 2019 update of the EULAR recommendations for vaccination in adult patients with AIIRD. RMD Open. 2019 Sep 19;5(2):e001041. doi: 10.1136/rmdopen-2019-001041.

  3. Furer V, et al. Point of view on the vaccination against COVID-19 in patients with autoimmune inflammatory rheumatic diseases. RMD Open. 2021 Feb;7(1):e001594. doi: 10.1136/rmdopen-2021-001594.

  4. Scanzi F, et al. Are the autoimmune/inflammatory syndrome induced by adjuvants (ASIA) and the undifferentiated connective tissue disease (UCTD) related to each other? A case-control study of environmental exposures. Immunol Res. 2017 Feb;65(1):150–156. doi: 10.1007/s12026-017-8912-4.

  5. Tunitsky-Lifshitz Y, et al. The third dose of BNT162b2 COVID-19 vaccine is efficacious and safe for systemic lupus erythematosus patients receiving belimumab. Lupus. 2023 Apr;32(5):675–679. doi: 10.1177/09612033231164262.

  6. Kharouf F, et al. A deep look into the storm: Israeli multi-center experience of coronavirus disease 2019 (COVID-19) in patients with autoimmune inflammatory rheumatic diseases before and after vaccinations. Front Immunol. 2023 Mar 13;14:1064839. doi: 10.3389/fimmu.2023.1064839

Learning Objectives

  • Describe immunization protocols that may enable safe and efficacious immunization

  • Discuss updated recommendations for immunization of AIIRD patients, in particular those with SLE

  • Discuss plausible options to lower immunogenicity among SLE patients

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