Review article
Systemic lupus erythematosus and vaccination

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Abstract

Patients with systemic lupus erythematosus (SLE) are frequently immunodepressed making them more vulnerable to infections. Preventive vaccination is therefore warranted but has often been withheld owing to fears of a link between infection and autoimmunity, and the possibility of inducing or exacerbating lupus after vaccination. The data published in the literature suggest that vaccination of lupus patient is safe, except for live vaccines. Their efficacy is lower than in healthy subjects but protection seems to be sufficient. But further large-scale studies are required to confirm these statements.

Introduction

Systemic lupus erythematosus (SLE) is one of the most frequent systemic autoimmune disorders. Patients with SLE may also be immunodepressed, either spontaneously or following treatment, making them more vulnerable to infections.

Several questions must be posed when envisaging a possible link between vaccination and autoimmunity: Is there a link between infection, vaccination and autoimmunity? Are patients with lupus at risk of infections that warrant vaccination? Can vaccines cause lupus? Is vaccination risky in patients with lupus? Is it effective? and are there any relevant practice guidelines?

Section snippets

Autoimmunity and vaccination

The human immune system is highly complex, having developed from simpler invertebrate systems to fight a broad spectrum of pathogens. This capacity to respond to a plethora of foreign antigens creates a risk of autoimmunity. Mechanisms have evolved in parallel to control this risk of autoimmunity, such as depletion of autoreactive B cells in bone marrow and autoreactive T lymphocytes in the thymus, but they cannot be perfect [1]. Indeed, excessive negative selection would restrict the

Infections and lupus

Infections are a major cause of morbidity and mortality in patients with lupus, and are the main cause in developing countries. Indeed, in a Brazilian autopsy series of 113 patients, 58% of deaths were linked to an infection and only 34% to lupus itself [11]. In a French prospective cohort of 87 patients, 20% of deaths were due to infections and 28% to lupus [12]. In a European multicenter series of 1000 patients, lupus and infections were together responsible for more than half the deaths [13].

Vaccination and de novo lupus

There are few reported cases of lupus onset after vaccination, especially in view of the millions of subjects who have been vaccinated. The incriminated vaccines were against tetanus [27], typhoid [28], hepatitis B [29], [30] anthrax, and combinations of these diseases [31]. A link is conceivable, however, especially as some patients may have a genetic susceptibility to vaccine-induced autoimmune disorders.

A lupus aggravation after vaccination is also theoretically possible. In the following

Conclusion

Patients with systemic lupus erythematosus are at a high risk of infections. Preventive vaccination is therefore warranted but has often been withheld owing to fears of a link between infection and autoimmunity, and the possibility of inducing or exacerbating lupus after vaccination. The literature contains only rare cases of potentially vaccine-related lupus, and vaccination of lupus patients against influenza, pneumococcal disease and hepatitis B appears to be safe [50]. If efficacy is lower

Learning points

  • Patients with systemic lupus erythematosus are at a high risk of infections.

  • Vaccination of lupus patient seems to be safe, except for live vaccines.

  • Their efficacy is lower than in healthy subjects but protection appears to be sufficient.

  • New therapies have not been studied yet to know if they are compatible with immunization in lupus patient.

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