Dear Editor,

Several studies have recently documented a low rate of immunizations in patients with rheumatoid arthritis (RA) [1]. It is also well documented that patients with RA and other chronic rheumatic diseases have a twofold higher risk for infections compared to the general population [2]. According to the Hellenic National Department of Health guidelines, all immunosuppressed patients should be vaccinated against influenza. We would like to add our own experience with Greek RA patients and their influenza vaccination status. We conducted an audit looking at the frequency of preventive influenza vaccination in Greek patients with RA and explored the factors that influence vaccine administration. Data were collected prospectively from randomly selected patients with RA, seen at outpatient clinics of three different hospitals in Athens, between February and September 2006. A standard questionnaire regarding patient demographics, recent influenza vaccination status during the winter 2005–2006, and current medication use (disease-modifying antirheumatic drugs (DMARDs) or other) was completed for each patient. None of the patients refused to fill in the questionnaire. There was no difference regarding the demographics of the RA patients among the three hospitals. The audit relied on patient recall about their vaccination status and this was a potential source of inaccuracy. One hundred thirty one patients (91 females, 40 males), with a mean age of 62 years and mean disease duration of 6 years, were included in the study. One hundred twenty three (94%) of them were receiving DMARDs and 40 (31%) were on corticosteroids. DMARDs used were: methotrexate [n = 74 (60%)], leflunomide [n = 34 (28%)], hydroxychloroquine [n = 5 (4%)], and cyclosporine [10 (8%)]. Biologic agents were used in seven patients (5%), anakinra [n = 3 (2%)], adalimumab [n = 2 (2%)], and etanercept [n = 2 (2%)]. Overall, 47 RA patients (36%) had been vaccinated during the previous winter season; 37 patients (27%) did so following the recommendation of their family doctor (general practitioner) while only ten (7.6%) after the advice of their rheumatologist. Eighty-two patients (62%) had not received influenza vaccination due to lack of any professional recommendation. Two (1, 5%) patients declined to have any vaccination.

The vaccination rate in this Greek RA population was suboptimal as only one third (36%) of patients had received routine influenza vaccination. Interestingly, this figure is similar to those reported from other European countries, despite the differences in the structure of the health care system [1, 3]. The main reason for this low rate of vaccination was the absence of appropriate recommendation by the caring physician (especially rheumatologists). It is obvious that there is an unmet need for the proper education of physicians and patients alike for the utility of influenza vaccination [4, 5]. We suggest that the International League of Associations for Rheumatology should issue guidelines about the appropriate use of influenza vaccination in rheumatic patients and at the same time launch an International campaign aiming at the better education of RA patients about the same issue.