Make sure your vaccinations are up to date.
By Linda Rath | Updated Jan. 27, 2023
If you take drugs that suppress your immune system, you may worry about the effect of your medications on vaccine effectiveness as well as the effect of vaccines on your disease. Here’s the latest information, including updated vaccination recommendations from the American College of Rheumatology (ACR).
Who needs it: Everyone aged 6 months and older, but which COVID-19 vaccines you need and the best time to get them depend on:
- Your age
- The first vaccine you received
- How long it’s been since your last dose or booster shot
- Whether you’re immunocompromised or take immunosuppressant drugs
- Your personal circumstances and preferences (for example, if you’ve recently had COVID-19, you may still have some natural immunity or want to hold off on a vaccine in general)
Adults and kids who are immunocompromised or take immunosuppressant drugs, including high-dose corticosteroids, methotrexate or tumor necrosis factor (TNF) blockers or other biologics, need a third shot as part of their primary series.
Boosters are intended to boost immunity when original vaccine protection starts to wane, usually within four to six months.
The CDC advises that anyone age 5 and older get a booster if it’s been at least two months since your vaccine or a previous booster. Some experts recommend waiting longer, so your body has more time to develop immunity.
In October 2022, the Centers for Disease Control and Prevention (CDC) authorized a Novavax booster for adults aged 18 and older. It’s intended as a first booster only and isn’t an option if you’ve had other boosters.
Immunocompromised people should consider getting a booster after their third dose. In May 2022, the CDC recommended a second booster for adults aged 50 and older and those who are immunocompromised or at high risk of hospitalization and death from the coronavirus.
What is an updated booster?
If you got a booster shot before September 2022, it was intended to shore up fading immunity to the original SARS-CoV-2 strain. In September, a new, updated booster became available. It’s called a bivalent shot because it targets both the original strain and now-dominant Omicron variants BA.4 and BA.5.
Some experts say including the original strain in the shot provides a broader immune response, even though the virus has mutated considerably over the past two-plus years. It’s also hoped the bivalent shot may provide better protection against Omicron variants such as XBB and BQ.1 and BQ.1.1.
A small study in a preprint that has not yet been peer-reviewed challenges both ideas. In that study, researchers compared the antibody responses of people who had received three or four shots of the original monovalent vaccine with people who had received a bivalent shot as a fourth dose. They found no difference between the two. This is an early study of a small number of people and probably not the last word on the bivalent vaccine.
It’s still recommended that everyone aged 5 and up who is eligible for a booster get the new bivalent shot, even if they have already received other boosters.
Peter Marks, MD, director of the Center for Biologics Evaluation and Research at the Food and Drug Administration (FDA) acknowledges that mRNA vaccine effectiveness is short-lived and that it’s not possible, practical or cost-effective for at-risk people to keep getting boosters every few months. He is encouraging drug manufacturers to come up with more durable options using other platforms. An FDA advisory committee has recommended sunsetting the original vaccines and considering some sort of regular bivalent vaccination schedule, as with the flu shot, especially for more vulnerable older people.
Are there other options?
In January 2023, the FDA withdrew its emergency use authorization for Evusheld, a combination drug designed to help prevent COVID-19 in people with moderate to severe immune suppression due to disease or immunosuppressing medications. It is not effective against omicron subvariants of the coronavirus, which now dominate.
The coronavirus changes quickly. To keep up to date, read our COVID-19 FAQs and listen to experts in our COVID-19 related webinars.
Who needs it: The CDC recommends seasonal flu shots for almost everyone over 6 months of age. This includes people who have a rheumatic disease or take drugs that suppress the immune system, though they may not respond as well to the vaccine as other people.
Flu vaccines are updated every year in the U.S. based on past seasons and forecasts of how the virus might change. Overall, flu vaccine effectiveness ranges from 40% to 60%. But in the five years leading up to the coronavirus pandemic, effectiveness was only 29% to 48%, meaning the shot protected one-third to about one-half of people who received it. The vaccine’s performance in the 2021-2022 season was less than 16%, according to the CDC.
Even in years when the vaccine more closely matches circulating flu strains, it’s not as effective in older adults. That’s partly because the body’s immune response weakens with age. For the 2022-2023 flu season, the CDC designated three vaccines specifically for people over 65: Fluzone High-Dose Quadrivalent vaccine, Flublok Quadrivalent recombinant flu vaccine and Fluad Quadrivalent, a vaccine that contains an ingredient called an adjuvant that may help improve immune response. All three vaccines claim to offer better immunity for older adults.
The ACR conditionally recommends high-dose or adjuvanted flu vaccines for adults aged 18 and older who take immunosuppressants. Since these recommendations are outside the approved age range, your insurance may not cover this type of flu shot. Before getting one, discuss your flu vaccine options with your doctor and insurance company.
One option if you take methotrexate or rituximab is to stop the drug for one or two weeks after immunization; this may make it more effective.
If you take immunosuppressants, are immunocompromised or over age 50, you should not get a vaccine made from a live virus, such as the nasal vaccine (FluMist Quadrivalent).
It’s convenient and generally safe to get the flu and COVID shot together, but timing is important. Aim to get the flu shot by the end of October. Getting it too early means its effectiveness could wear off before the end of flu season in May. This may not always coincide with your COVID vaccine schedule.
To be sure the adjuvants in mRNA vaccines don’t interfere with the uptake of the flu vaccine, some experts recommend getting the shots in separate arms. And if you have a particularly strong reaction to vaccines, such as fever, chills, headache and fatigue, it’s better not to combine them.
HERPES ZOSTER/SHINGLES VACCINE
Who needs it: The CDC recommends the Shingrix vaccine for adults aged 50 and older, including those who are immunocompromised. It’s the first shingles vaccine approved for immunocompromised people. The Shingrix vaccine is also recommended if you ever received the Zostavax vaccine – a live vaccine no longer used in the U.S. – have already had shingles, take drugs that suppress your immune system or aren’t sure if you’ve had chickenpox. After a bout of chicken pox, the varicella zoster virus hibernates in your body and may re-emerge years later as shingles. COVID-19 vaccines can reactivate the varicella zoster virus in some people, especially those with inflammatory forms of arthritis.
The Shingrix vaccine is given in two doses, two to six months apart. It’s about 90% effective, even for people with autoimmune diseases.
Protects against: Bacteria that can cause pneumonia, sinus and ear infections, meningitis and bloodstream infections
Who needs it: The CDC recommends the pneumonia vaccine for children under age 2, unvaccinated adults over age 65 and kids and adults with certain chronic conditions, such as diabetes, heart disease, lung disease, HIV, sickle cell disease or who smoke, have a cochlear implant or are immunosuppressed.
The type of vaccine and vaccine schedule depend on your age, health and previous pneumonia vaccines. For example, if you’re aged 65 or older and have never had the pneumonia vaccine, you may receive a shot of PCV 15 followed by PPSCV about a year later – sooner if you have certain medical conditions. If you receive the PCV20 first, you won’t need a follow-up shot.
The ACR recommends the pneumonia vaccine for people under 65 who are on medications that suppress the immune system, though they’re not likely to have a robust response to it. If you have inflammatory arthritis, discuss the timing of the vaccine with your doctor. Ideally, you should get it before you start immunosuppressant drugs or when your disease isn’t active.
PERTUSSIS/WHOPPING COUGH VACCINE
Protects against: a severe respiratory infection that can be fatal in infants and debilitating in adults
Who needs it: Those 19 or older who haven’t had a Tdap (tetanus, diphtheria and pertussis) booster
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