For two reasons. First, because there are faults within their immune (protective) system as a consequence of the disease. Second, because the steroid and immunosuppressive drugs used as treatments have the side effect of reducing the body's ability to protect itself against infection.

Most people with lupus “react” normally. The real question is to what extent the degree of protection against the individual bacterium/virus is compromised by the disease and its treatment, and that is much harder to answer.

The absence of 'official' recommendations is what led us to write the review! However, after we gathered and analyzed the available information, we developed these recommendations:

• A thorough assessment of the patient's vaccination status should be done before beginning treatment with a biologic agent.
• Vaccination can be administered during therapy with anti-TNF alpha agents, tocilizumab, and abatacept (Orencia®), but ideally should be given before B cell-depleting agents such as rituximab (Rituxan®).
• Live attenuated vaccines should be avoided, notably in anyone taking more than 10mg daily of any corticosteroid, or taking an immunosuppressive drug such as mycophenolate mofetil (CellCept®), cyclophosphamide, or azathioprine (Imuran®), or taking biologic agents.
• The influenza and pneumococcal vaccines are strongly recommended.
• Tetanus toxoid vaccination should be administered as in the general population, except if the patient has been treated with rituximab within the last 24 weeks and is at high risk of developing tetanus, in which case passive immunization with tetanus immunoglobulin is strongly advised.

Regrettably, there are no data at this time to help advise patients taking biologics with respect to the use of these vaccines.