Early in the coronavirus pandemic, it became clear that COVID-19 could cause serious disruptions to the immune system in some people. For people with autoimmune diseases, in which the immune system erroneously attacks tissues or cells in the body that it shouldn’t be targeting, these potential hyper-immune responses associated with COVID-19 infection were worrying.
Autoimmune diseases are a broad class of diseases that take many forms. From Celiac disease to rheumatoid arthritis, lupus and Crohn’s disease, there are at least 90 autoimmune diseases currently known to science and more being discovered all the time. Autoimmune diseases affect anywhere from 15 to 24 million Americans, and research suggests that incidences of autoimmune diseases are on the rise.
Under the autoimmune disease umbrella, there’s a lot of variation in specific conditions and how they manifest in the body. For example, some like ulcerative colitis, cause digestive issues while others such as multiple sclerosis cause nerve signaling problems. Having one autoimmune disease makes you much more likely to have another, so some people have complex disease states that can vary greatly from person to person.
In the context of COVID-19 and the vaccinations that can prevent it, there’s still a lot of open questions when it comes to protecting people with autoimmune diseases. The different autoimmune conditions “vary tremendously in how they affect the immune system, so determining how the body will respond to these vaccines is likely very complex,” says Dr. Julita Mir, a practicing internist and infectious disease physician and chief medical officer of Community Care Cooperative (C3) in Boston.
Given all this complexity, there’s still a lot to be learned about how COVID-19 affects people with one or more autoimmune conditions, and how they will respond to the vaccine.
Is the Vaccine Safe for People with Autoimmune Diseases?
Sandy Boek Werness, executive director of the McLean, Virginia–based Global Autoimmune Institute, an advocacy organization supporting research into and education about autoimmune diseases, says “there’s currently no concrete data to elucidate how the immune system responds to the (COVID-19) vaccine specifically in those with autoimmune disease.”
However, the Centers for Disease Control and Prevention stated that people with autoimmune conditions were eligible for enrollment in COVID-19 vaccine clinical trials and that “no imbalances were observed in the occurrence of symptoms consistent with autoimmune conditions or inflammatory disorders in clinical trial participants who received COVID-19 vaccine compared to placebo.”
Werness says that “this finding suggests that people with autoimmune conditions may safely receive any FDA-authorized COVID-19 vaccine.”
Is the Vaccine Effective in People With Autoimmune Disease?
Whether vaccines are effective in people with autoimmune disease is a more difficult question to answer because “patients treated with systematic immunosuppressants or immune-modifying drugs” were excluded from some or all phases of clinical trials of the Pfizer-BioNTech and the Moderna vaccines, says Dr. Anca D. Askanase, a member of the Lupus Foundation of America Medical-Scientific Advisory Council, director of the Columbia University Lupus Center and associate professor of medicine in the division of rheumatology at Columbia University College of Physicians & Surgeons in New York City.
Both the Pfizer and Moderna vaccines use mRNA, or messenger RNA, snippets of genetic code that instruct cells to develop antibodies against the coronavirus.
The vaccines leverage the immune system to fight back against the virus, but people with autoimmune disease have altered immune system function. Their immune response is different not just because of the disease, but also in some cases because of the treatment they’re receiving for their autoimmune condition — typically immunosuppressant medications. These medications tamp down the overactive immune system response to reduce symptoms. As a result, immunosuppressants can inhibit the immune system from doing what it would normally do — creating antibodies to fight back against a virus or other pathogen.
“Any disorder that decreases the body’s ability to fight diseases and develop antibodies will also affect how effective the vaccine will be,” Mir says.
Werness agrees. “The current understanding is that COVID-19 vaccine efficacy may be decreased for people who take immunosuppressant drugs, which includes many being treated for autoimmune disease.”
People with autoimmune diseases or “active autoimmune disease requiring therapeutic intervention were specifically excluded from Phase 1” of the Pfizer vaccine trial, Askanase adds.
Because of these restrictions, “the population of patients with autoimmune conditions was underrepresented in the clinical trials,” Askanase says. As a result, “published data regarding the safety and efficacy of vaccines in patients with autoimmune disorders, especially those receiving immunosuppressive treatment,” may not be adequate to say for sure how the vaccines will impact someone with an autoimmune condition.
Thus, there’s not a clear answer just yet as to exactly how effective the vaccine is in people who have autoimmune disease or who are receiving treatment for an autoimmune disease that involves immunosuppressants.
Werness adds that what we know so far varies based on the type of autoimmune disorder. “Inflammatory and autoimmune rheumatic diseases have been the focus of research and studies thus far regarding the COVID-19 vaccine and people with autoimmune disease. Patients with autoimmune rheumatic disease who are taking immunosuppressants have been shown to produce fewer antibodies to the COVID-19 vaccine.”
Mir also adds that how long immunity from the vaccine will last in people with autoimmune conditions is still an open question. “More studies that include patients with autoimmune disorders are needed in order to draw a steady conclusion.”
As we learn more, it may become clearer that people with autoimmune diseases or those on immunosuppressive treatments may “require more intensive vaccination strategies such as dose adjustment and/or extra booster (shots) to achieve adequate and durable immune responses,” Askanase says.
As research continues, Mir is “confident that in the months to come, we’ll have more information about the level of protection for those with autoimmune disorders and, perhaps, if serologies (checking for antibodies) is recommended.”
Should I Get the Vaccine if I’m Being Treated for an Autoimmune Disease?
Currently, the CDC, the American College of Rheumatology and many other public health entities are encouraging people with autoimmune diseases to take the vaccine because they’re at higher risk of complications from getting COVID-19.
In addition to higher risk of incidence of severe disease in people with autoimmune conditions, these individuals are also at increased risk of severe or long-haul COVID. Therefore, Werness says “from what the Global Autoimmune Institute has reviewed in the scientific literature in regards to COVID-19 vaccination and those with autoimmune disease, we have determined that the evidence available at this point indicates that the benefit of COVID-19 vaccination outweighs any possible side effect risks.”
If you’re taking immunosuppressants, the American College of Rheumatology recommends delaying taking such medications for one week after vaccination — under the direction of your doctor. “Doing this may allow their immune systems to create a stronger antibody response and combat the drop in vaccine efficacy seen in those on immunosuppressants,” Werness says.
But you should only do so on the advice of your doctor. Talk with your care team about your specific situation.
Mir says she and other practitioners at C3 are encouraging people with autoimmune diseases to take the vaccine, “but we recognize their concerns and respect any decision to opt out. If they do opt out, our providers reinforce that they need to follow proper safety measures (such as wearing masks, practicing social distancing and keeping up with good hand hygiene practices) because they’re at increased risk for severe COVID-19 symptoms.”
Askanase notes that when it comes to vaccines in general, “the safety of routine immunizations against common pathogens has been well established” in patients with systemic lupus erythematosus, the most common form of the autoimmune disease lupus. She notes that these patients have received vaccinations against many other diseases including pneumonia, human papilloma virus, the flu and the chickenpox with very minimal side effects.
In weighing the benefits versus the risks, Askanase says that the vaccines currently available in the U.S. “are crucial in protecting patients with autoimmune disease from a disease with high mortality and morbidity and therefore should be strongly recommended to all patients with autoimmune diseases while monitoring their clinical activity.”
Mir adds that “the current research suggests that the benefits of the COVID-19 vaccines in fighting the potential of severe symptoms from the virus outweigh any potential reaction to the vaccine.”
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