Editor’s Note: We recently were asked about the measles outbreak and the risk to those on TNF inhibitors. We forwarded the question to Dr. Lianne Gensler, who serves on SAA’s Medical & Scientific Advisory Board. Below is that Q & A. Our thanks to Dr. Gensler for her thorough and informative reply! We hope you find the information helpful.
“Lately, there has been a lot in the news about the measles outbreak. It made me think about vaccinations and the prevalence of parents not to vaccinate in my state. In some areas of my state, the vaccination rate is only 50%.
“I am an AS patient on Remicade and I tend to catch every infection and virus that is going around among adults and children. I know that the risks with Remicade are mainly fungal and bacterial, but I am thinking that my immune system is so out of whack that viruses (I catch a virus every other week during flu season) are a problem, too. I would love some advice. Thanks!”
Answer from: Lianne S. Gensler, M.D., Associate Professor of Medicine; Director, Ankylosing Spondylitis Clinic, University of California, San Francisco
Measles is a type of virus that had largely disappeared because of a very good vaccine, the MMR. Because some people did not get vaccinated, measles has begun to resurface. What is the risk to AS patients on a TNF inhibitor?
There are several issues:
- Any immunocompromised patient (TNF inhibitors included) is at increased risk of infection. We have no data on what the risk is with measles specifically, but I expect it would be a little higher than the general population. Keep in mind, that though there have been several cases recently, it is still quite rare compared to far more common viruses, like influenza.
- If a patient on a TNF inhibitor has a child that has been vaccinated, this will help protect the whole family as you can only transmit the infection once infected, and it is expected the vaccination will prevent this.
- If a patient is worried about their measles immune status (because they were vaccinated a long time ago or even had measles) they could check a blood level to determine if there is persistent immunity. This would be reassuring if positive.
- What about revaccinating? We sometimes boost patients if they lose immunity and before they are pregnant. Unfortunately, the MMR is a live vaccine, so if a patient is on a biologic, the vaccine would be contraindicated. A patient would have to let the biologic wash out of the system and then stay off of it for a period before restarting after vaccination.
- If a patient without immunity is exposed (and particularly one that is immunocompromised), immunoglobulin (antibodies) can be given, if available. Note that they are temporary and do not protect individuals long-term.
- An unanswered question is whether we should be checking immunity before initiating a TNF inhibitor with the recent resurgence of measles. It is certainly making me rethink my practice pattern, which does not currently indicate this test, based on lack of evidence. As science and diseases evolve, so too will our practice of medicine to keep patients as safe as possible.