Source: This guide follows the Expert Panel Consensus Statements on Vaccination for Adults with AIRD in India — developed by the Indian Rheumatology Association Vaccine (IRAVAC) group and published in the Indian Journal of Rheumatology, 2024 (48 statements; rheumatologists, infectious-disease specialists, a virologist, an epidemiologist and a patient representative). Where the Indian consensus doesn't cover a vaccine, that's said explicitly. This is general guidance — your own plan is set in consultation.
The three things to understand first
Non-live vaccines are safeFlu, pneumococcal, hepatitis, tetanus, rabies and the recombinant shingles vaccine can be given on rheumatology medicines — they do not flare the disease.
Timing changes how well they workSome medicines lower the antibody response. Giving vaccines before starting treatment, or pausing a medicine briefly, can make them work much better.
Live vaccines are the exceptionYellow fever, oral polio, oral typhoid, MMR, chickenpox, BCG and the nasal flu spray need a case-by-case decision — usually completed before treatment, and avoided during significant immunosuppression.
The overarching rule from the Indian consensus: every patient with an autoimmune rheumatic disease should have their vaccination status reviewed once a year, and appropriate vaccines considered after assessing their individual risk. Bring your vaccination record to your review.
Before you start treatment — the checklist
The single most useful window is before methotrexate, biologics or rituximab begin. Response is best, and there are no timing constraints yet.
- Pneumococcal vaccine — PCV13 first, then PPSV23 at least 8 weeks later (the "prime-boost" approach)Best given before starting methotrexate, which reduces the response. Recommended for everyone with lupus before immunosuppressive treatment, whatever the disease activity.
- Hepatitis B — check your status; vaccinate if not immuneResponse is adequate, but on immunosuppression you may need extra doses or a higher dose. Your rheumatologist will check antibody levels.
- Annual flu vaccine — the inactivated (injected) oneCan be given at any point, but the earlier the better.
- Any live vaccines you'll need — e.g. yellow fever for travelComplete these well before treatment starts; they become difficult once immunosuppression begins.
- TB screening before biologicsNot a vaccine, but essential in India — your rheumatologist will arrange this before any biologic.
The flu vaccine — the one to get every year
The inactivated influenza vaccine is safe and works well across rheumatoid arthritis, lupus, vasculitis, scleroderma, myositis and spondyloarthritis — including on treatment. What changes with your medicine is timing:
| Your medicine | What the Indian consensus says |
|---|---|
| Hydroxychloroquine | No effect on the vaccine — take it any time. |
| Methotrexate | Response is adequate. Consider pausing methotrexate for 2 weeks after the vaccine where possible — trials show this improves the response without causing a flare. |
| Anti-TNF biologics | Adequate response — can be given at any time. |
| Abatacept, secukinumab, tocilizumab | Can be given at any time. |
| Tofacitinib (JAK inhibitor) | Adequate response — any time; no need to pause. |
| Rituximab | Response is low close to an infusion. Vaccinate 4 weeks before starting rituximab, or 12 weeks after the last dose. If rituximab can't be delayed, it's decided case by case. |
| Any biologic | An extra dose 3–4 weeks after the first can boost the response. |
| Steroids | Ideally given while prednisolone is under 10 mg/day. |
| Lupus on immunosuppression | Response can be lower — a booster dose may be considered; vaccinate in a quiet phase; if you missed last year, catch up at the first chance. |
The pneumococcal vaccine — protects against pneumonia
Two vaccines are used in India: PCV13 (conjugate) and PPSV23 (polysaccharide). For people on immunosuppression the recommended approach is PCV13 first, then PPSV23 at least 8 weeks later. It works in rheumatoid arthritis, lupus, vasculitis, Sjögren's and scleroderma, and does not cause flares.
| Your medicine | What the Indian consensus says |
|---|---|
| Methotrexate | Reduces the response. Best given before starting methotrexate. If already on it, methotrexate could be withheld for 2 weeks around the vaccine, where possible. |
| Anti-TNF biologics | Adequate response — any time. |
| Rituximab | Reduced response — give 4 weeks before starting rituximab whenever possible. |
| Tocilizumab, baricitinib, tofacitinib | Adequate response — can be given. |
| Lupus | Recommended for all before immunosuppressive therapy, regardless of disease activity. |
Who responds less well: the consensus notes that early disease onset, older age, high disease activity and immunosuppressive therapy all reduce the pneumococcal response — one more reason to vaccinate before treatment when you can.
Other vaccines — quick reference
| Vaccine | Indian consensus position |
|---|---|
| Hepatitis A | Adequate response on immunosuppression; can be given (a full course, not a single dose). |
| Hepatitis B | Adequate response and safe. On immunosuppression, extra cycles or higher doses may be needed. |
| Shingles (herpes zoster) | The recombinant, non-live zoster vaccine is safe and effective in people over 50 with rheumatic disease. (Especially relevant before or on JAK inhibitors, which raise shingles risk.) |
| Rabies (after a bite) | Always take post-exposure vaccination — immunosuppression is not a reason to skip it. Follow the Government of India protocol for immunocompromised patients, which includes an antibody check 14 days after the course. |
| Tetanus (after injury) | Post-exposure vaccination should be given as usual. |
| Yellow fever (live) | Case by case only — considered when disease is quiet and immunosuppression is low-dose. Response is inadequate on combined conventional + biologic DMARDs. Not approved by EULAR/ACR for these conditions; discuss well before travel. |
| COVID-19, HPV, typhoid, JE, meningococcal, MMR, polio | Not covered by the 2024 Indian consensus (insufficient India-specific data). Decisions follow international guidance (EULAR/ACR) and your rheumatologist's advice. |
A practical way to think about it
- Newly diagnosed, about to start treatment? Get pneumococcal (both doses), check hepatitis B, and take the flu vaccine — before the first dose of methotrexate or a biologic.
- Already on methotrexate? Take the flu and pneumococcal vaccines; ask whether to pause methotrexate for 2 weeks after.
- On a biologic (anti-TNF, tocilizumab, secukinumab, abatacept)? Non-live vaccines any time. Consider an extra flu dose 3–4 weeks later.
- Due for rituximab? Vaccinate 4 weeks before the infusion. Already on it? Wait 12 weeks after the last dose for flu.
- On a JAK inhibitor, over 50? Ask about the recombinant shingles vaccine.
- Travelling? Plan early — inactivated travel vaccines are fine; live ones need a decision.
- Bitten by an animal? Full rabies course, no exceptions.
Bring your vaccination card to your next visit. A yearly vaccination review is part of good rheumatology care, not an add-on.
Common questions
Can I take vaccines while on biologics?+
Yes — inactivated (non-live) vaccines such as flu, pneumococcal, hepatitis A/B, tetanus, rabies and the recombinant shingles vaccine are safe on biologics and do not flare the disease. The response may be a little lower on some medicines, which is why timing matters. Live vaccines are the exception and are decided case by case.
Should I stop methotrexate for the flu vaccine?+
The Indian consensus suggests pausing methotrexate for 2 weeks after the flu vaccine, where possible, because trials show this improves the antibody response without causing a flare. Do this only after confirming with your rheumatologist.
I'm about to start rituximab. When should I get vaccinated?+
Ideally 4 weeks before the first rituximab dose. If you're already on it, the best window is at least 12 weeks after the last dose (for flu) — response is much lower close to an infusion.
Which vaccines should I complete before starting treatment?+
Pneumococcal (PCV13 then PPSV23) is best given before starting methotrexate or immunosuppression, and is recommended for everyone with lupus before treatment. Check hepatitis B status. Complete any live vaccines you need well before starting.
Is the shingles vaccine safe on rheumatology medicines?+
The recombinant, non-live zoster vaccine is safe and effective for people over 50 with rheumatic disease, including on treatment. The older live zoster vaccine is different and generally avoided on immunosuppression.
What if I'm bitten by a dog while on biologics?+
Get the full post-exposure rabies course without delay — being on immunosuppression is not a reason to skip it. The Government of India protocol for immunocompromised patients also checks antibody levels 14 days after the course to confirm protection.
Can I travel abroad and take travel vaccines?+
Most travel vaccines are inactivated and fine. Yellow fever is a live vaccine — the consensus allows it only case by case, when disease is quiet and immunosuppression is low, and not on combinations of conventional plus biologic DMARDs. Discuss well before travel.
Will a vaccine make my arthritis or lupus flare?+
The evidence says no for inactivated vaccines — flu and pneumococcal vaccines have not been shown to increase flares in rheumatoid arthritis or lupus. In lupus, vaccinating during a quiet phase is preferred.
Starting a new treatment, or unsure about a vaccine?
Vaccination planning is part of every treatment decision at the clinic. Consultations are walk-in — no appointment needed.
Clinic timings & location