Patients with systemic autoimmune rheumatic disease were excluded from the RSV vaccine trials, which leaves rheumatologists advising on a vaccine with no direct evidence. This systematic review searched to January 2026 and found 49 studies.
The gaps are stark. Only one study reported RSV outcomes in patients with systemic autoimmune rheumatic disease at all. Not one evaluated vaccine effectiveness by DMARD class. What exists comes from broader immunocompromised populations: first-season effectiveness of 60 to 73 per cent, with evidence that protection is both attenuated and wanes more rapidly than in immunocompetent adults. Immunogenicity data across RSV and other vaccine platforms show reduced seroconversion under immunosuppression. Observational data link autoimmune and immunocompromising conditions to higher RSV-associated hospitalisation, though the authors flag bias and attribution problems. No consistent autoimmune safety signal emerged.
The practical position the authors land on — vaccinate eligible patients using a personalised framework — is the right one, and it is worth saying out loud in clinic that the effectiveness figure quoted to the general population does not apply unchanged to someone on rituximab. In India, where RSV vaccination is not part of any routine adult schedule and cost is entirely out of pocket, the conversation is about whether it is worth buying rather than whether to give it.
- Offer RSV vaccination to eligible older patients with autoimmune rheumatic disease; the safety signal is reassuring
- Say explicitly that protection is likely lower and shorter-lived under immunosuppression
- Time vaccination relative to B-cell depleting therapy where you can, as you would for other vaccines
- Do not quote general-population effectiveness figures unqualified
- Note the complete absence of DMARD-stratified data when a patient asks about their specific drug
Why it matters
Every RSV vaccine conversation in this clinic is currently being had with evidence borrowed from a different population.
Don't overread it
The 60 to 73 per cent effectiveness comes from immunocompromised adults generally, not from patients with rheumatic disease on DMARDs.
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