Low Rates of Vaccination Among Atopic Dermatitis, Alopecia Areata, Psoriasis, and Psoriatic Arthritis Patients on Biologics

doi:10.21203/rs.3.rs-4278889/v1

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Low Rates of Vaccination Among Atopic Dermatitis, Alopecia Areata, Psoriasis, and Psoriatic Arthritis Patients on Biologics

https://doi.org/10.21203/rs.3.rs-4278889/v1

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published 25 May, 2024

Read the published version in Archives of Dermatological Research →

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Biologics and Janus kinase (JAK) inhibitors are immunomodulating and immunosuppressing medications, respectively, utilized to treat atopic dermatitis (AD), psoriasis (PSO), psoriatic arthritis (PsA), and alopecia areata (AA). Special recommendations must be considered when prescribing vaccinations in this population, as the pneumococcal and herpes zoster vaccine are recommended to patients ≥ 19-years-old (rather than ≥ 65-years-old and ≥ 50-years-old as in the general population, respectively), along with a yearly influenza and up to date COVID-19 vaccination. Additionally, TNF-α and JAK-inhibitors may increase the risk of latent Hepatitis B virus (HBV) reactivation among high-risk patients. Prior to prescribing these medications, a quantitative HepB Surface Antibody (HepB SA) test is performed to determine immunity. This study utilized the SlicerDicer function on EPIC Medical Records to search for any patient ≥ 19-years-old prescribed a biologic or JAK inhibitor for AD, PSO, PsA, or AA between 10/2003–10/2023 at a large tertiary institution. Vaccination rates among patients on biologics and JAK inhibitors were low, with rates being significantly lower in patients 19–64 years-old, compared to those ≥ 65 years-old for most disease states (p < 0.01). Among AD, PSO/PsA, and AA patients, on average, 9.39% were vaccinated for influenza, 6.76% for herpes zoster, 16.56% for pneumococcal pneumonia, and 63.98% for COVID-19. Only 3.16% of patients were adequately vaccinated for HepB after an abnormal HepB SA test. Here, extremely low rates of vaccination among patients on biologics and JAK inhibitors at our institution were highlighted, emphasizing the imperative need for ensuring vaccination in this patient group.

biologics

vaccinations

Janus kinase inhibitors

atopic dermatitis

psoriasis

alopecia areata

Injectable biologics and oral Janus kinase (JAK) inhibitors have revolutionized the treatment of several inflammatory diseases, with USA Federal Drug Administration (FDA) approval in atopic dermatitis (AD), psoriasis (PSO), psoriatic arthritis (PsA), and alopecia areata (AA). However, these medications are considered immunomodulators (biologics), and immunosuppressants (JAK inhibitors), and therefore, special recommendations must be considered when prescribing vaccinations in this population [1].

Unlike the general population, for which the pneumococcal vaccine is recommended in adults ≥ 65-years-old and the herpes zoster vaccine is recommended for adults ≥ 50-years-old, both vaccinations are recommended to those ≥ 19-years-old who are being treated with immunosuppressive drugs. A yearly influenza vaccine and up to date COVID-19 vaccination are recommended to all, especially for patients on systemic therapies for AD, PSO, PsA, and AA [1].

Additionally, there is an increased risk of reactivation of latent Hepatitis B virus (HBV), among patients prescribed certain biologics (TNF-α inhibitors) and JAK inhibitors. Testing for latent HBV is recommended prior to treatment with these molecules [2–3]. For high-risk patients (elderly, patients at high-risk for HBV exposure, or patients with distant history of HepB vaccination), a quantitative HepB Surface Antibody (HepB SA) test can be administered to determine immunity [4]. Among those with low HepB SA titers, it is important to ensure vaccination is current.

Previous studies investigating vaccination compliance in biologic and JAK inhibitor-prescribed patients tend to focus on one specific type of vaccination or disease, have small sample sizes, or lack discussion on Hepatitis B vaccination [5, 6]. Herein, we create a comprehensive report detailing the rates of vaccination against several diseases among patients on biologics/JAK inhibitors diagnosed with either AD, PSO, PsA, or AA at a large tertiary academic center, and detail rates of HBV vaccination in high-risk patients.

EPIC Electronic Medical Records was utilized to search for any patient ≥ 19 years-old prescribed a biologic or JAK inhibitor for AD, PSO, PsA, or AA between October 2003– October 2023 at a large academic center. Using the SlicerDicer function on EPIC, this data was then categorized based on ICD-10-codes, prescribed biologic or JAK inhibitor, and vaccination status based on desired year (Supplemental Table I). SlicerDicer is an EPIC application that provides aggregate population data based on the user’s restrictions. Thus, specific dates, the number of patients with a chosen diagnosis and medication prescribed within those dates, and vaccination rates among populations can be queried using this application. Supplemental Table I depicts the constraints which were applied to yield the data described in Table I. The data was also stratified as patients ≥ 65 years-old (elderly), versus 19 to 64 years-olds (non-elderly). Statistical differences in vaccination rates between these populations was calculated using the χ2 test (p-value < 0.01 was considered statistically significant). The percentage of patients with an abnormal HepB SA quantification titer between October 2018 – October 2023 who did not receive proper follow-up vaccination was quantified per disease state and vaccination type (Table I).

Overall, rates of vaccination among patients on biologics or JAK inhibitors were low, with elderly patients being significantly more likely to be vaccinated against influenza, herpes zoster, pneumococcal pneumonia, and COVID-19 than non-elderly patients, in both AD and PSO/PsA (p < 0.01) (Fig. 1). In alopecia areata, elderly patients were significantly more likely to be vaccinated against herpes zoster and pneumococcal pneumonia than non-elderly patients. Among patients diagnosed with AD, PSO/PsA, and AA, on average, 9.39% were vaccinated for influenza, 6.76% for herpes zoster, 16.56% for pneumococcal pneumonia, and 63.98% for COVID-19. Only 3.16% of patients were effectively vaccinated against Hepatitis B after receiving an abnormal HepB SA quantification laboratory test (Table I).

Patients prescribed biologics and JAK inhibitors lacked proper vaccination, more so in those aged 19–64 years-old, versus those ≥ 65 years-old. The significantly higher rates of vaccination among elderly patients on biologics or JAK inhibitors is likely due to the generally higher rates of vaccination among elderly patients [7]. The rate of vaccination against COVID-19 was higher than other reported vaccinations. The authors surmise this was likely due to the large public health drive for COVID-19 vaccination during the pandemic.

Additionally, these results showed HepB vaccination among patients prescribed TNF-α inhibitors or JAK inhibitors was extremely low, with an average of only 3.16% of patients with an abnormal HepB SA quantification test receiving a HepB vaccination prior to starting medication. Despite receiving an abnormal test result, these patients did not receive HepB vaccination, indicating a lack of follow-up.

These results highlight the imperative need for educating patients on the importance of vaccination. Previous research shows patients with negative attitudes towards vaccinations, and barriers to primary care were least likely to be vaccinated. However, those with knowledge of the need for vaccination are more likely to stay up to date [8, 9]. A cross-sectional study examining patients initiating biologic treatment for rheumatological indications in Spain found the highest rates of pneumococcal and influenza vaccination were among patients who received a referral to a vaccine unit, highlighting the importance of vaccination follow-up [10].

In conclusion, vaccination rates remain low among patients prescribed biologics and JAK inhibitors for AD, PSO/PsA, and AA, and are significantly lower among patients aged 19–64, as compared to those who are ≥ 65 years-old for all vaccinations in AD and PSO/PsA, and for herpes zoster and pneumococcal pneumonia vaccination in patients with AA. Further, most patients prescribed TNF-α inhibitors and JAK inhibitors with abnormal HepB SA test lacked proper vaccination, indicating lack of follow-up. Education on vaccine importance and vaccination referral are imperative factors in ensuring compliance. Vaccination is a simple method to avoid infection with preventable illnesses, therefore, this necessity must not be overlooked in this high-risk population.

Funding

This research was not funded by any sources

Ethics approval

This work was IRB exempt, by the Mount Sinai, Icahn School of Medicine Institutional Review Board.

Author Contribution

SK conceived of the presented idea and supervised this research.MGH wrote the main manuscript and prepared Table I, Figure I, and Supplemental Table I.All authors reviewed the manuscript.

Statements and Declarations

The authors did not receive support from any organization for the submitted work. The authors have no conflicts of interest to declare that are relevant to the content of this article.

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Table I: Rates of Vaccination Among Patients with Atopic Dermatitis, Psoriasis/Psoriatic Arthritis, or Alopecia Areata

Vaccine	Total Pts	# Vaccinated	% Vaccinated	% age 19–65 vaccinated	% ≥65 vaccinated	Dates Included
Atopic Dermatitis
Influenza	3117	313	10.04	8.69	16.51	1/2023–1/2024
Herpes Zoster	4507	244	5.41	2.85	16.93	10/2017–10/2023
Pneumococcal¹	4538	690	15.20	11.20	33.25	10/2003–10/2023
COVID-19¹	3907	2550	65.27	63.46	73.76	12/2020–10/2023
Abnormal HepB SA Quant + Follow-up Vaccination^b	72	2	2.78	-	-	10/2018–10/2023
Psoriasis or Psoriatic Arthritis
Influenza	5184	474	9.14	7.69	13.08	1/2023–1/2024
Herpes Zoster	6632	509	7.67	4.58	16.18	10/2017–10/2023
Pneumococcal^a	7046	1243	17.64	12.65	31.11	10/2003–10/2023
COVID-19^a	5800	3652	62.97	61.95	65.76	12/2020–10/2023
Abnormal HepB SA Quant + Follow-up Vaccination^b	83	2	2.41	-	-	10/2018–10/2023
Alopecia Areata
Influenza	182	10	5.49	4.36	13.64	1/2023–1/2024
Herpes Zoster	170	11	6.47	3.97	26.32	10/2017–10/2023
Pneumococcal^a	170	14	8.24	4.64	36.84	10/2003–10/2023
COVID-19^a	150	105	70.00	60.00	78.94	12/2020–10/2023
Abnormal Hep B SA Quant + Follow-up Vaccination^b	35	2	5.71	-	-	10/2018–10/2023
AD, PSO/PsA, AA Total Vaccinated
Influenza	-	-	9.39	-	-	1/2021–1/2022
Herpes Zoster	-	-	6.76	-	-	10/2017–10/2023
Pneumococcal	-	-	16.56	-	-	10/2003–10/2023
COVID-19	-	-	63.98	-	-	12/2020–10/2023
HepB After Abnormal SA Quant	-	-	3.16	-	-	10/2018–10/2023
Average	-	-	-	21.71	34.00

Table I This table shows the total number of patients prescribed each biologic or JAK inhibitor for a specific diagnosis within the indicated timeframe. The total number of patients vaccinated, along with the total percentage vaccinated is indicated. The percent vaccinated < 65 years-old, along with the percent vaccinated ≥ 65 years-old is also indicated.

a – At least ONE vaccination in series was obtained.

b – Total patients in this row includes only those who received an abnormal Hepatitis B Surface Antibody Quantification titer prior to starting biologic or small molecule inhibitor therapy.

Abbreviations: SA, surface antibody; Quant, quantification; Hep; hepatitis, AD, atopic dermatitis; PSO, psoriasis; PsA, psoriatic arthritis; AA, alopecia areata

No competing interests reported.

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Journal Publication

published 25 May, 2024

Read the published version in Archives of Dermatological Research →

Editorial decision: Accepted
26 Apr, 2024
Reviews received at journal
26 Apr, 2024
Reviewers agreed at journal
26 Apr, 2024
Reviewers invited by journal
26 Apr, 2024
Submission checks completed at journal
17 Apr, 2024
Editor assigned by journal
17 Apr, 2024
First submitted to journal
16 Apr, 2024

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Low Rates of Vaccination Among Atopic Dermatitis, Alopecia Areata, Psoriasis, and Psoriatic Arthritis Patients on Biologics

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