Rheumatology International

, Volume 36, Issue 9, pp 1255–1263 | Cite as

Influenza and pneumococcal vaccination in patients with rheumatoid arthritis in comparison with age- and sex-matched controls: results of a claims data analysis

  • A. Luque RamosEmail author
  • F. Hoffmann
  • J. Callhoff
  • A. Zink
  • K. Albrecht
Public Health


The aim of this study was to assess the vaccination status for influenza and pneumonia and the prevalence of hospitalised pneumonia in rheumatoid arthritis (RA) patients and population controls in Germany. Members of a large statutory health insurance fund in Germany who were continuously insured between 2009 and 2013 and had a diagnosis of RA in 2013 were age and sex matched 1:5 to members without RA. Pneumococcal and influenza vaccinations were evaluated with regard to age, sex and region of residence. Logistic regression models were used to determine predictors for influenza vaccination in RA patients. Prevalences of pneumonia that required hospitalisation were compared to regional vaccination rates. The data of 111,482 RA patients and 557,410 matched controls were available for analysis. Compared to controls, RA patients were vaccinated more frequently against influenza (40.8 vs. 32.2 %) and pneumonia (15.0 vs. 10.0 %). Vaccination rates increased with older age and differed between the federal states (highest in East Germany, lowest in South Germany). The region of residence, comorbidities, rheumatologic care and biologic treatment was associated with a higher probability of an influenza vaccination. Prevalences of pneumonia that required hospitalisation were 2–3 times higher in patients compared to controls and tended to be higher in regions with low vaccination rates. The increased pneumonia prevalence in RA patients confirms their status as a risk group. RA patients are vaccinated more frequently than controls, but vaccination rates are still low. The lower pneumonia prevalence in East Germany indicates that vaccination may help to reduce pneumonia in RA.


Rheumatoid arthritis Vaccination Influenza Pneumonia 



The study was sponsored by the Federal Ministry of Education and Research (01EC1405).

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

Although no ethical approval is required for the analysis of claims data, an ethics vote for PROCLAIR study, which also includes surveys of patients identified via claims data, was obtained from the Ethics Committee of the Charité University Medicine, Berlin in 2015 (EA1/051/15). This claims data analysis does not contain personal information. In this case, an informed consent is not necessary in Germany.


  1. 1.
    Doran MF, Crowson CS, Pond GR et al (2002) Frequency of infection in patients with rheumatoid arthritis compared with controls: a population-based study. Arthritis Rheum 46:2287–2293CrossRefPubMedGoogle Scholar
  2. 2.
    Bernatsky S, Hudson M, Suissa S (2007) Anti-rheumatic drug use and risk of serious infections in rheumatoid arthritis. Rheumatology 46:1157–1160CrossRefPubMedGoogle Scholar
  3. 3.
    Listing J, Gerhold K, Zink A (2013) The risk of infections associated with rheumatoid arthritis, with its comorbidity and treatment. Rheumatology 52:53–61CrossRefPubMedGoogle Scholar
  4. 4.
    Smitten AL, Choi HK, Hochberg MC et al (2008) The risk of hospitalized infection in patients with rheumatoid arthritis. J Rheumatol 35:387–393PubMedGoogle Scholar
  5. 5.
    Blumentals WA, Arreglado A, Napalkov P, Toovey S (2012) Rheumatoid arthritis and the incidence of influenza and influenza-related complications: a retrospective cohort study. BMC Musculoskelet Disord 13:158CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Wotton CJ, Goldacre MJ (2012) Risk of invasive pneumococcal disease in people admitted to hospital with selected immune-mediated diseases: record linkage cohort analyses. J Epidemiol Community Health 66:1177–1181CrossRefPubMedGoogle Scholar
  7. 7.
    Ehreth J (2003) The global value of vaccination. Vaccine 21:596–600CrossRefPubMedGoogle Scholar
  8. 8.
    van Assen S, Agmon-Levin N, Elkayam O et al (2011) EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 70:414–422CrossRefPubMedGoogle Scholar
  9. 9.
    van Assen S, Holvast A, Benne CA et al (2010) Humoral responses after influenza vaccination are severely reduced in patients with rheumatoid arthritis treated with rituximab. Arthritis Rheum 62:75–81CrossRefPubMedGoogle Scholar
  10. 10.
    Bingham CO 3rd, Looney RJ, Deodhar A et al (2010) Immunization responses in rheumatoid arthritis patients treated with rituximab: results from a controlled clinical trial. Arthritis Rheum 62:64–74CrossRefPubMedGoogle Scholar
  11. 11.
    Robert Koch-Institut (2015) Empfehlungen der ständigen Impfkommision (STIKO) am Robert Koch-Institut. Epidemiol Bull. Accessed 17 Feb 2016
  12. 12.
    Wiese-Posselt M, Tertilt C, Zepp F (2011) Vaccination recommendations for Germany. Dtsch Arztebl Int 108:771–779PubMedPubMedCentralGoogle Scholar
  13. 13.
    Warnatz K, Goldacker S, Gause AM (2013) Vaccination recommendations of the Commission for Pharmacotherapy of the German Society of Rheumatology. Z Rheumatol 72:687–689CrossRefPubMedGoogle Scholar
  14. 14.
    Feuchtenberger M, Kleinert S, Schwab S et al (2012) Vaccination survey in patients with rheumatoid arthritis: a cross-sectional study. Rheumatol Int 32:1533–1539CrossRefPubMedGoogle Scholar
  15. 15.
    Hmamouchi I, Winthrop K, Launay O, Dougados M (2015) Low rate of influenza and pneumococcal vaccine coverage in rheumatoid arthritis: data from the international COMORA cohort. Vaccine 33:1446–1452CrossRefPubMedGoogle Scholar
  16. 16.
    Hense S, Ramos AL, Callhoff J et al. (2016) Prävalenz der rheumatoiden Arthritis in Kassendaten—Regionale Unterschiede und erste Ergebnisse der PROCLAIR Studie. Z Rheumatol. doi: 10.1007/s00393-016-0088-0 PubMedGoogle Scholar
  17. 17.
    Chung CP, Rohan P, Krishnaswami S, McPheeters ML (2013) A systematic review of validated methods for identifying patients with rheumatoid arthritis using administrative or claims data. Vaccine 31(Suppl 1):41–61CrossRefGoogle Scholar
  18. 18.
    Widdifield J, Labrecque J, Lix L et al (2013) Systematic review and critical appraisal of validation studies to identify rheumatic diseases in health administrative databases. Arthritis Care Res 65:1490–1503CrossRefGoogle Scholar
  19. 19.
    Achtymichuk KA, Johnson JA, Al Sayah F, Eurich DT (2015) Characteristics and health behaviors of diabetic patients receiving influenza vaccination. Vaccine 33:3549–3555CrossRefPubMedGoogle Scholar
  20. 20.
    Shrank WH, Patrick AR, Brookhart MA (2011) Healthy user and related biases in observational studies of preventive interventions: a primer for physicians. J Gen Intern Med 26:546–550CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Costello R, Winthrop KL, Pye SR et al (2016) Influenza and pneumococcal vaccination uptake in patients with rheumatoid arthritis treated with immunosuppressive therapy in the UK: a retrospective cohort study using data from the clinical practice research datalink. PLoS One 11:e0153848CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Reuss AM, Walter D, Feig M et al (2010) Influenza vaccination coverage in the 2004/05, 2005/06, and 2006/07 seasons: a secondary data analysis based on billing data of the German associations of statutory health insurance physicians. Dtsch Arztebl Int 107:845–850PubMedPubMedCentralGoogle Scholar
  23. 23.
    Theidel U, Kuhlmann A, Braem A (2013) Pneumococcal vaccination rates in adults in Germany: an analysis of statutory health insurance data on more than 850,000 individuals. Dtsch Arztebl Int 110:743–750PubMedPubMedCentralGoogle Scholar
  24. 24.
    Poethko-Müller C, Schmitz R (2013) Impfstatus von Erwachsenen in Deutschland. Ergebnisse der Studie zur Gesundheit Erwachsener in Deutschland. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 56:845–857CrossRefPubMedGoogle Scholar
  25. 25.
    Meyer C, Reiter S (2004) Impfgegner und Impfskeptiker. Geschichte, Hintergründe, Thesen. Umgang. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 47:1182–1188CrossRefGoogle Scholar
  26. 26.
    Riens B, Mangiapane S, Erhard M, von Stillfried D (2012) Analyse regionaler Unterschiede der Influenza-Impfraten in der Impsaison 2007/2008. Accessed 17 Feb 2016
  27. 27.
    Fine MJ, Auble TE, Yealy DM et al (1997) A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 336:243–250CrossRefPubMedGoogle Scholar
  28. 28.
    Lim WS, van der Eerden MM, Laing R et al (2003) Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58:377–382CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Lim WS, Baudouin SV, George RC et al (2009) BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 64(Suppl 3):31–55CrossRefGoogle Scholar
  30. 30.
    Jackson LA, Nelson JC, Benson P et al (2006) Functional status is a confounder of the association of influenza vaccine and risk of all cause mortality in seniors. Int J Epidemiol 35:345–352CrossRefPubMedGoogle Scholar
  31. 31.
    Fendler C, Saracbasi E, Dybowski F et al (2012) Practical problems by implementation of vaccination recommendations. Z Rheumatol 71:147–155CrossRefPubMedGoogle Scholar
  32. 32.
    Michel M, Vincent FB, Rio S et al. (2016) Influenza vaccination status in rheumatoid arthritis and spondyloarthritis patients receiving biologic DMARDs. J Bone Spine 83:237–238CrossRefGoogle Scholar
  33. 33.
    Hua C, Morel J, Ardouin E et al (2015) Reasons for non-vaccination in French rheumatoid arthritis and spondyloarthritis patients. Rheumatology 54:748–750CrossRefPubMedGoogle Scholar
  34. 34.
    Hoffmann F, Icks A (2012) Unterschiede in der Versichertenstruktur von Krankenkassen und deren Auswirkungen für die Versorgungsforschung: Ergebnisse des Bertelsmann-Gesundheitsmonitors. Gesundheitswesen 74:291–297CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  1. 1.Department of Health Services ResearchCarl von Ossietzky UniversityOldenburgGermany
  2. 2.EpidemiologyGerman Rheumatism Research CentreBerlinGermany
  3. 3.Department of Rheumatology and Clinical ImmunologyCharité University HospitalBerlinGermany

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