EULAR 2026: Updated Recommendations for Vaccination in Patients with Autoimmune Inflammatory Rheumatic Diseases Save

The 2026 EULAR vaccination recommendations, presented by Victoria Furer, were developed by a multinational 25-member task force that include rheumatologists, an infectious disease specialist, and patient advocates after a systematic literature review and evidence consensus. This update includes new pandemic era evidence, recombinant zoster vaccine data, and new perspectives on vaccination in patients taking novel immunosuppressants. These recommendations promote vaccination to prevent infections in patients with autoimmune inflammatory rheumatic diseases (AIIRD). Recommendations are presented based on strength of recommendation (SoR) and level of agreement (LoA) by the panelists (on a 1-10 scale).

The overarching principles advocate for being proactive: vaccinate early, regardless of disease activity, and have a vaccination plan starting with diagnosis.

5 Overarching Principles

• Assess vaccination status at diagnosis and annually
• Develop an individualized vaccination program through shared decision-making
• Vaccinate as soon as possible, independent of disease activity (new)
• Non-live vaccines can be administered safely regardless of treatment
• Live-attenuated vaccines may be considered with caution

10 Vaccine Recommendations

1. Influenza — Strongly recommended for all AIIRD patients (SoR A, LoA 9.5). High-dose vaccine preferred over standard-dose in immunosuppressed patients. Holding methotrexate (MTX) for 1-2 weeks post-vaccination improves humoral responses; a 1-week hold is non-inferior to a 2-week hold, with only modest risk of flare.
2. Pneumococcal — Strongly recommended (SoR A, LoA 9.6). AIIRD patients face a 4-fold increased risk of invasive pneumococcal disease and severe pneumonia. Conjugated vaccines (e.g., PCV20, PCV13) are preferred. The VACIMRA study (with PCV13 vaccine) confirms that delaying MTX initiation by 1 month to vaccinate first significantly improves immunogenicity without compromising 1-year RA disease control.
3. Tetanus — Standard recommendations apply (SoR B/D, LoA 9.7). Seroprotection exceeds 90% after boosters in SpA and vasculitis. Passive immunization should be considered in patients on cell-depleting therapy.
4. Hepatitis A and B — As the prevalence of HBV is low in AIIRD patients, vaccination is only recommended for those at risk (SoR B, LoA 9.3). Immunogenicity is reduced particularly with TNFi; additional doses and post-vaccination antibody assessment (target ≥10 mIU/mL) are advised, with booster if subthreshold.
5. Herpes Zoster — Strongly recommended for AIIRD patients on immunosuppressive treatment (SoR A, LoA 9.5). The recombinant zoster vaccine (RZV/Shingrix) has been a major advance over the former live virus HZV vaccine (Zostavax), that is no longer available. The ZOE 50 trial showed 90.5% vaccine efficacy in AIIRD patients, with no increased disease flares. Humoral immunogenicity is relatively preserved on JAKi, though cellular responses are attenuated and further reduced with concomitant MTX. (Editors note: the highest risk of herpes zoster is seen in patients receiving JAK inhibitors and alpha interferon inhibitors [e.g., anifrolumab])
6. Yellow Fever — Generally avoided in AIIRD patients (SoR C, LoA 9.4). May be considered on an individualized basis in patients on low-level immunosuppression or after temporary biologic withdrawal.
7. HPV — Strongly recommended in accordance with general population guidelines (SoR B, LoA 9.5). Catch-up vaccination is especially emphasized in SLE patients, who face twice the risk of cervical precancer and up to 5-fold higher risk of non-cervical anogenital precancers.
8. Household Contacts — Immunocompetent household members should vaccinate per national guidelines (SoR D, LoA 9.5). Oral polio vaccine is explicitly excluded due to fecal shedding and neurovirulence risk; diaper handling precautions apply for 4 weeks after rotavirus vaccination.
9. Newborns Exposed in Utero to bDMARDs — Live vaccines should generally be avoided until 6 months post-delivery (SoR C, LoA 9.3). Exception: rotavirus vaccine may be given to infants with antenatal TNFi exposure, supported by prospective cohort data from 168 infants with no serious adverse events.
10. SARS-CoV-2 — Strongly recommended for all AIIRD patients (SoR A, LoA 9.3), backed by 58 systematic literature review studies demonstrating a highly favorable benefit-risk profile with adequate immunogenicity and safety across AIIRD populations.

The 2026 EULAR vaccination recommendation promote planned, early vaccination regardless of disease activity, and tailor timing around key immunosuppressants, especially B cell-depleting therapies, to maximize immune protection.