Rheumatic and musculoskeletal diseases (RMDs) affect over 10 million people in the UK, with approximately 400,000 of those patients living with a Rheumatoid Arthritis (RA) diagnosis.1,2 These patient cohorts have an increased risk of respiratory infections,3 with the mortality rate from such infections much higher than the general population.4 Whilst there is evidence to suggest RA and other autoimmune diseases themselves may contribute to the enhanced infection risk, this is also caused secondary to immunosuppressive therapy.5
Vaccination is a well-established, effective preventative strategy in immunosuppressed patients. The UK national immunisation programme is described in the Green Book6 and recommends certain vaccines for immunosuppressed individuals.
Despite this, reports from the UKHSA describe suboptimal uptake of recommended vaccines in immunosuppressed patients:
- Influenza – Patients ≤65 with immunosuppression: 47.2%.7
- COVID-19 - Patients ≤65 in a clinical risk group: 23.6%.8
- Pneumococcal – patients ≤65 with immunosuppression: 43.4%.9
- Shingles – patients ≥ 50 with severe immunosuppression: Dose 1 = 19.3%.10 Dose 2 – 10.4%.10
Whilst patients with rheumatology-related conditions may be classified as immunosuppressed dependent on their treatment, very few studies have analysed uptake in rheumatology cohorts specifically, and of these, most demonstrate persistent gaps in implementation. Pneumococcal vaccination coverage, for example, remains below 40% in many immunosuppressed cohorts. In a recent study published in Rheumatology,11 pneumococcal vaccine uptake in people with inflammatory arthritis was 35%, significantly lower than for influenza (63%) or COVID-19 (87%). The study examined over 900 patients with rheumatoid arthritis, psoriatic arthritis, or axial spondyloarthritis and found that age ≥65 and biologic therapy were the strongest predictors of vaccine uptake. This indicates that younger patients and those not yet escalated to biologic treatment - precisely the group for whom early vaccination is most immunologically effective - are being left behind.
This is of clinical significance given that pneumococcal pneumonia and influenza remain leading causes of hospitalisation and vaccine-preventable mortality. Invasive pneumococcal disease can lead to bacteraemia, meningitis, and long-term disability. Moreover, some immune-modulating treatments such as B cell depleting agents blunt vaccine responses, making early vaccination, before escalation of therapy, essential. Patients with immune mediated inflammatory diseases (IMIDs) have a 1.5–2-fold higher risk of herpes Zoster compared with healthy individuals, both due to their underlying disease and immunosuppressive medications.12
This project aims to establish a national measurement system and develop evidence-based intervention approaches to improve timely vaccination in individuals newly diagnosed with rheumatology-related conditions who are commencing immunosuppressive therapy.
The objectives are to:
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Establish a real-time national measurement system for vaccine uptake in patients with rheumatic diseases using OpenSAFELY.
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Using outputs from the BSR National Early inflammatory arthritis audit (NEIAA), describe current vaccine uptake rates and identify geographic, demographic, and provider-level variation across England.
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Map vaccination delivery pathways and identify systemic barriers through comprehensive stakeholder engagement.
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Develop and advocate for evidence-informed policy recommendations for the NHS including relevant professional bodies at the patient, provider, and system level.
Planned start date: 8th October 2025.
Planned end date: 7th October 2026.