Rheumatology · Medical Literature
Vaccination coverage of influenza and pneumococcal vaccines in patients with rheumatic diseases: a systematic review and meta-analysis.
Abstract
Current guidelines recommend influenza and pneumococcal vaccination in the majority of patients with rheumatic diseases. This study aimed to summarize the coverage of influenza and pneumococcal vaccines among these patients. A literature search was conducted in PubMed, Embase, Web of Science and Scopus for eligible studies. Vaccination rate was presented as a percentage with 95% CI. Clinical characteristics of the vaccinated patients were shown as the mean difference or odds ratio with 95% CI. Sensitivity analyses, subgroup analyses and meta-regression were performed to identify sources of heterogeneity. A total of 51 studies were identified. The pooled vaccination rates of influenza vaccine in patients with RA, SLE, SpA and PsA were 50%, 42%, 43% and 53%, respectively. The corresponding rates of pneumococcal vaccination in patients were 37%, 30%, 39% and 41%, respectively. Compared with unvaccinated RA patients, vaccinated RA patients were associated with older age and an increased prevalence of comorbidities. Geographical location and use of DMARDs were two significant factors affecting the heterogeneity of the study results. A larger proportion of patients received vaccine education from rheumatologists rather than general practitioners, and the two major reasons for not receiving vaccination were 'lack of awareness' and 'not offered by doctors'. Influenza and pneumococcal vaccine coverage was still suboptimal in patients with rheumatic diseases. Enhancing vaccine education from physicians and improving awareness of patients may become two important approaches to improve vaccination rates.
Clinical relevance
What are the pooled vaccination coverage rates for influenza and pneumococcal vaccines among patients with rheumatic diseases (RA, SLE, SpA, PsA), and what patient- and system-level factors are associated with vaccine uptake? __SNAPSHOT__ {"studyDesign":"Systematic review and meta-analysis","setting":"International; multiple countries across geographically diverse settings (specific countries not individually enumerated in abstract)","sampleSize":"51 studies included; individual patient-level N not reported in abstract","population":"Patients with rheumatic diseases including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), spondyloarthritis (SpA), and psoriatic arthritis (PsA)","intervention":"Influenza vaccine and pneumococcal vaccine receipt (vaccination coverage assessment)","comparator":"Unvaccinated patients with the same rheumatic diagnoses (for subgroup comparisons within RA); not applicable for primary coverage estimation","primaryOutcome":"Pooled vaccination rate (percentage with 95% CI) for influenza and pneumococcal vaccines by rheumatic disease subtype","followUp":"Not reported (cross-sectional coverage data aggregated across included studies)","fundingSource":"Not reported"}
Key findings
Across 51 included studies, pooled influenza vaccination rates were: RA 50%, SLE 42%, SpA 43%, and PsA 53%. Pooled pneumococcal vaccination rates were consistently lower across all diagnoses: RA 37%, SLE 30%, SpA 39%, and PsA 41%. Pneumococcal vaccine coverage lagged behind influenza coverage by approximately 8–13 percentage points across all four conditions (calculated). All pooled estimates were presented as percentages with 95% CIs; specific CI values were not reported in the abstract. Compared with unvaccinated RA patients, vaccinated RA patients were older and had a higher prevalence of comorbidities (effect size expressed as mean difference or odds ratio per the methods, specific values not reported in abstract). Geographical location and DMARD use were identified as statistically significant sources of heterogeneity across studies via subgroup analyses and meta-regression. A higher proportion of patients received vaccine education from rheumatologists than from general practitioners. The most commonly cited reasons for non-vaccination included lack of awareness of vaccination recommendations and not receiving a physician recommendation (abstract truncated; further reasons not reported). No NNT/NNH calculable from aggregate coverage data.
Practice implications
This meta-analysis establishes that influenza and pneumococcal vaccination coverage in patients with RA, SLE, SpA, and PsA is substantially below recommended targets across international settings, with fewer than half of most subgroups receiving either vaccine. Pneumococcal coverage is uniformly lower than influenza coverage, suggesting a relative de-prioritization of this vaccine in clinical practice. The finding that vaccinated RA patients tend to be older and have more comorbidities suggests a 'sick but engaged' phenotype — patients without comorbid conditions may be systematically under-vaccinated. DMARD use as a heterogeneity driver raises the clinically important question of whether immunosuppressive therapy is functioning as both an indication and a barrier for vaccination, though causal directionality cannot be determined from this design. Rheumatologists appear to be more active than GPs in providing vaccine education, supporting a specialist-driven vaccination promotion model. Importantly, this analysis characterizes coverage rates rather than vaccine effectiveness or safety in this population; it does not establish causality or inform whether vaccination reduces infection-related morbidity in these specific patients. Results may not be uniformly generalizable given heterogeneity driven by geography and DMARD exposure. Only an abstract was available for review; full methods, individual study-level data, funnel plot assessment for publication bias, and complete CI ranges were not evaluable. __LIMITATIONS__ Only the abstract was available; full methodological detail (risk of bias assessment tools, specific heterogeneity statistics such as I², funnel plot/publication bias evaluation) could not be verified.,High expected heterogeneity across 51 studies spanning multiple countries, healthcare systems, time periods, and rheumatic disease definitions; geographic location and DMARD use identified as significant — but not fully explanatory — sources of heterogeneity.,Cross-sectional coverage data from observational studies preclude causal inference about factors driving vaccination uptake or non-uptake.,Vaccination was self-reported in many primary studies, introducing recall bias and likely overestimation of true coverage.,Disease severity, disease activity scores, specific DMARD classes (csDMARDs vs. bDMARDs vs. JAK inhibitors), and healthcare access were inconsistently reported across included studies, limiting subgroup granularity.,The pooled estimates aggregate studies conducted across different time periods with evolving vaccination guidelines, potentially reducing contemporary clinical applicability.,Funding source not reported; cannot assess potential sponsorship bias.,Patients from lower- and middle-income countries may be underrepresented, limiting global generalizability.,The abstract was truncated; complete data on barriers to vaccination and additional sensitivity analyses were not fully available for review. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ Influenza and pneumococcal vaccination coverage remains well below recommended levels across all major rheumatic disease subtypes internationally, with pneumococcal coverage consistently lower than influenza coverage. Older patients and those with comorbidities are more likely to be vaccinated, while lack of provider recommendation and patient unawareness are the predominant barriers. Rheumatologists should proactively assess and recommend both vaccines at every clinical encounter, particularly for younger patients and those without apparent comorbidities.