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Original research
Early experience of COVID-19 vaccination in adults with systemic rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance Vaccine Survey
  1. Sebastian Eduardo Sattui1,
  2. Jean W Liew2,
  3. Kevin Kennedy3,
  4. Emily Sirotich4,
  5. Michael Putman5,
  6. Tarin T Moni6,
  7. Akpabio Akpabio7,
  8. Deshiré Alpízar-Rodríguez8,
  9. Francis Berenbaum9,
  10. Inita Bulina10,
  11. Richard Conway11,
  12. Aman Dev Singh12,
  13. Eimear Duff13,
  14. Karen L Durrant14,
  15. Tamer A Gheita15,
  16. Catherine L Hill16,17,
  17. Richard A Howard18,
  18. Bimba F Hoyer19,
  19. Evelyn Hsieh20,21,
  20. Lina El Kibbi22,
  21. Adam Kilian23,
  22. Alfred Hyoungju Kim24,
  23. David F L Liew25,26,
  24. Chieh Lo27,
  25. Bruce Miller28,
  26. Serena Mingolla29,
  27. Michal Nudel30,
  28. Candace A Palmerlee31,
  29. Jasvinder A Singh32,33,
  30. Namrata Singh34,
  31. Manuel Francisco Ugarte-Gil35,36,
  32. John Wallace37,
  33. Kristen J Young38,
  34. Suleman Bhana39,
  35. Wendy Costello40,
  36. Rebecca Grainger41,
  37. Pedro M Machado42,43,
  38. Philip C Robinson44,45,
  39. Paul Sufka46,
  40. Zachary S Wallace47,48,
  41. Jinoos Yazdany49,
  42. Carly Harrison50,
  43. Maggie Larché51,
  44. Mitchell Levine52,
  45. Gary Foster53,
  46. Lehana Thabane52,
  47. Lisa G Rider54,
  48. Jonathan S Hausmann48,55,56,
  49. Julia F Simard57,58 and
  50. Jeffrey A Sparks48,59
  1. 1Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
  2. 2Section of Rheumatology, Boston University School of Medicine, Boston, Massachusetts, USA
  3. 3Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
  4. 4Medicine, McMaster University, Hamilton, Ontario, Canada
  5. 5Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  6. 6Department of Biochemistry & Biomedical Sciences, McMaster University Faculty of Science, Hamilton, Ontario, Canada
  7. 7Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
  8. 8Research Unit, Mexican College of Rheumatology, Coyoacan, Ciudad de México, Mexico
  9. 9Rheumatology, Sorbonne Université, Paris, France
  10. 10Department of Internal Diseases, Rheumatology Centre, Paul Stradins Clinical University Hospital, Riga, Latvia
  11. 11Rheumatology, Saint James's Hospital, Dublin, Ireland
  12. 12Community Medicine, GMC Patiala, Punjab, India
  13. 13Department of Rheumatology, Saint James's Hospital, Dublin, Ireland
  14. 14Autoinflammatory Alliance, San Francisco, California, USA
  15. 15Rheumatology and Clinical Immunology, Faculty of Medicine, Cairo University, Cairo, Egypt
  16. 16Rheumatology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
  17. 17Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
  18. 18Spondylitis Association of America, Van Nuys, California, USA
  19. 19Medical Department I, Department for Rheumatology and Clinical Immunology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Schleswig-Holstein, Germany
  20. 20Section of Rheumatology, Allergy & Immunology, Yale School of Medicine, New Haven, Connecticut, USA
  21. 21Section of Rheumatology, VA Connecticut Healthcare System—West Haven Campus, West Haven, Connecticut, USA
  22. 22Rheumatology, Specialized Medical Center Hospital, Riyadh, Saudi Arabia
  23. 23Department of Internal Medicine, Division of Rheumatology, Saint Louis University, Saint Louis, Missouri, USA
  24. 24Medicine/Rheumatology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
  25. 25Rheumatology, Austin Health, Heidelberg West, Victoria, Australia
  26. 26Clinical Pharmacology and Therapeutics, Austin Health, Heidelberg, Victoria, Australia
  27. 27I-Shou University College of Medicine, Yanchau Sheng, Taiwan
  28. 28Medicine, University of California San Diego, La Jolla, California, USA
  29. 29Italian National Patient Association for Rehumatoid and Rare Disease (APMARR), Rome, Italy
  30. 30The Israeli Association for RMD Patients "Mifrakim Tz'eirim", Haifa, Israel
  31. 31Relapsing Polychondritis Foundation, International Relapsing Polychondritis Research Network, Walnut Creek, California, USA
  32. 32Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
  33. 33Medicine Service, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
  34. 34Medicine, Division of Rheumatology, University of Washington, Seattle, Washington, USA
  35. 35Department of Rheumatology, Universidad Cientifica del Sur, Lima, Peru
  36. 36Universidad Científica del Sur, Lima, Peru
  37. 37Autoinflammatory UK, Edinburgh, UK
  38. 38Division of Rheumatology, University of Texas Southwestern Medical School, Dallas, Texas, USA
  39. 39Crystal Run Healthcare, Middletown, New York, USA
  40. 40Irish Children's Arthritis Network (iCAN), Tipperary, Ireland
  41. 41Department of Medicine, Malaghan Institute of Medical Research, Wellington, New Zealand
  42. 42MRC Centre for Neuromuscular Diseases, University College London, London, UK
  43. 43Rheumatology, University College London Centre for Rheumatology, London, UK
  44. 44Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
  45. 45Metro North Hospital & Health Service, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
  46. 46Healthpartners, St Paul, Minnesota, USA
  47. 47Clinical Epidemiology Program and Rheumatology Unit, Division of Rheumatology,Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
  48. 48Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
  49. 49Medicine/Rheumatology, University of California, San Francisco, California, USA
  50. 50LupusChat, New York, New York, USA
  51. 51Division of Clinical Immunology and Allergy, McMaster University Department of Medicine, Hamilton, Ontario, Canada
  52. 52Department of Health Research Methods, Evidence and Impact (HEI), McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
  53. 53Department of Health Research Methods, Evidence, and Impact (HEI); Medicine, McMaster University, Hamilton, Ontario, Canada
  54. 54Environmental Autoimmunity Group, NIEHS/NIH/DHHS, Bethesda, Maryland, USA
  55. 55Rheumatology, Boston Children's Hospital, Boston, Massachusetts, USA
  56. 56Division of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  57. 57Epidemiology and Population Health and Department of Medicine, Division of Immunology & Rheumatology, Stanford School of Medicine, Stanford, California, USA
  58. 58Department of Medicine, Clinical Epidemiology Unit, Sweden
  59. 59Department of Medicine, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Jeffrey A Sparks; jsparks{at}


Background We describe the early experiences of adults with systemic rheumatic disease who received the COVID-19 vaccine.

Methods From 2 April to 30 April 2021, we conducted an online, international survey of adults with systemic rheumatic disease who received COVID-19 vaccination. We collected patient-reported data on clinician communication, beliefs and intent about discontinuing disease-modifying antirheumatic drugs (DMARDs) around the time of vaccination, and patient-reported adverse events after vaccination.

Results We analysed 2860 adults with systemic rheumatic diseases who received COVID-19 vaccination (mean age 55.3 years, 86.7% female, 86.3% white). Types of COVID-19 vaccines were Pfizer-BioNTech (53.2%), Oxford/AstraZeneca (22.6%), Moderna (21.3%), Janssen/Johnson & Johnson (1.7%) and others (1.2%). The most common rheumatic disease was rheumatoid arthritis (42.3%), and 81.2% of respondents were on a DMARD. The majority (81.9%) reported communicating with clinicians about vaccination. Most (66.9%) were willing to temporarily discontinue DMARDs to improve vaccine efficacy, although many (44.3%) were concerned about rheumatic disease flares. After vaccination, the most reported patient-reported adverse events were fatigue/somnolence (33.4%), headache (27.7%), muscle/joint pains (22.8%) and fever/chills (19.9%). Rheumatic disease flares that required medication changes occurred in 4.6%.

Conclusion Among adults with systemic rheumatic disease who received COVID-19 vaccination, patient-reported adverse events were typical of those reported in the general population. Most patients were willing to temporarily discontinue DMARDs to improve vaccine efficacy. The relatively low frequency of rheumatic disease flare requiring medications was reassuring.

  • COVID-19
  • vaccination
  • autoimmune diseases

Data availability statement

Data are available on reasonable request. Researchers interested in performing additional analyses from survey data are invited to submit proposals through the COVID-19 Global Rheumatology Alliance at For approved projects, we will be able to provide summary tables and data analyses as requested. We do not currently have IRB approval to make the raw data available to other researchers.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Key messages

What is already known about this subject?

  • People with systemic rheumatic diseases, who were largely excluded from COVID-19 vaccine clinical trials, may have additional concerns about the impact of their underlying disease or antirheumatic medications on COVID-19 vaccine response.

  • Studies of rheumatic disease flares following vaccination for other infections were previously reassuring, and studies from a physician-based registry and a prospective cohort have shown a low frequency of flares following COVID-19 vaccination.

What does this study add?

  • In this international online survey of adults with systemic rheumatic disease who received COVID-19 vaccination, patient-reported adverse events were typical of those reported in the general population, with rheumatic disease flare requiring medication changes occurring in <5%.

  • Most patients were willing to temporarily discontinue disease-modifying antirheumatic drugs in order to improve vaccine efficacy.

Key messages

How might this impact on clinical practice or further developments?

  • Clinicians should maintain awareness of changing guidelines as further data become available in order to provide continued communication and patient counselling regarding risks and benefits of vaccination.


Multiple COVID-19 vaccines have become available, with established safety and efficacy in the general population.1 However, people with systemic rheumatic diseases, who may have a unique risk and benefit profile, were largely excluded from the initial vaccine clinical trials. People with systemic rheumatic diseases may have specific concerns on how their underlying disease or their immunomodulatory therapies affect the benefit and safety of receiving COVID-19 vaccination.2 3 These concerns have been further complicated by heterogenous vaccine rollouts and access, and conflicting advice from clinicians in response to major organisation recommendations.4–6 There is a paucity of data regarding vaccinated patients with rheumatic diseases, and better information could inform decision making and guidance for clinicians and patients. This study describes a large, international survey of adults with systemic rheumatic disease who received a COVID-19 vaccine, focusing on their experiences communicating with clinicians, their beliefs about and management of medications for their rheumatic disease around the time of vaccination, and their experience with adverse events after vaccination.


Survey design and inclusion

The COVID-19 Global Rheumatology Alliance (C19-GRA) Vaccine Survey was developed and refined based on feedback from relevant stakeholders (clinicians, researchers and patient partners) and collaborators from December 2020 through March 2021. The survey collected information from both COVID-19 vaccinated and unvaccinated adults with systemic rheumatic diseases.

To study a more homogenous group and to obtain a better understanding of characteristics and factors associated with vaccination, this analysis was restricted to adults with systemic rheumatic diseases who received COVID-19 vaccination. Respondents were included if they completed the survey in English, Italian or Hebrew (first translations made available) between 2 April and 30 April 2021 and reported having received at least one dose of any COVID-19 vaccine. Respondents were excluded if they did not provide information on the following characteristics: age, sex, country of residence, race/ethnicity, rheumatic disease diagnosis and use of antirheumatic medications. Respondents reporting only diagnoses of osteoarthritis and/or only fibromyalgia without other systemic rheumatic diseases were also excluded.

The survey was administered online using the Qualtrics platform, an online survey software that allows for the creation and distribution of surveys and other measurement tools. After providing initial consent to participate, respondents were required to enter their year of birth and only received additional questions if they were over the age of 18 years. Where possible, participants were required to enter a response to questions before proceeding in order to minimise missing responses. Also, Internet Protocol address gating, restricting only one survey entry per individual (or source), was employed in order to secure integrity of responses and data.

Measures and data collection


Self-reported demographics including year of birth (from which age was calculated), sex assigned at birth, highest level of education, current employment and country of residence were collected. Country of residence was grouped by the WHO region.7 Race/Ethnicity was grouped into mutually exclusive categories: black, Asian (including East Asian, South Asian and West Asian), Hispanic, Latinx or Latin American, white, American Indian/Alaska Natives/Aboriginal/Indigenous/First Nations, Arab, Pacific Islander and multiple identities (ie, participants reporting more than one race/ethnicity).

Systemic rheumatic disease diagnosis and clinical information

Participants could report multiple systemic rheumatic disease diagnoses. Comorbidities were also collected and included over 30 possible selections. Patient global assessment of current rheumatic disease activity was self-reported using a patient global assessment of disease activity visual analogue scale from 0 (remission/very low disease activity) to 10 (very high disease activity).8

Disease-modifying antirheumatic drug, glucocorticoid and non-steroidal anti-inflammatory drug use

Participants reported the disease-modifying antirheumatic drugs (DMARDs), glucocorticoids and non-steroidal anti-inflammatory drugs (NSAIDs) that they were taking at the time of the survey. Medications were grouped into different classes according to mechanism of action, with a free text option to report additional medications. Free text was categorised into appropriate medication classes after translation.

DMARDs were categorised using the most recent American College of Rheumatology (ACR) COVID-19 Vaccine Clinical Guidance Summary.6 Medications, where holding or altered dosage timing around time of vaccination was recommended (methotrexate, abatacept, rituximab, Janus kinase (JAK) inhibitors) were grouped independently.

Communication with clinicians and medication changes

Participants were asked about vaccine-related communication and counselling by their clinicians. All survey respondents were asked about their general willingness to temporarily discontinue medications based on a 5-point Likert scale. In addition, for each specific medication that participants reported taking, they were asked if they would be willing to discontinue those medications (yes/no/unsure), to improve the effectiveness of a COVID-19 vaccine. They were also asked about their greatest concern(s) about temporarily discontinuing those medications. Finally, participants were asked if they held any medications before or after vaccination (yes/no/unsure).

Adverse events after vaccination

In addition to self-reported anaphylaxis, participants were asked about the occurrence of postvaccination adverse events, lasting >2 days and within 2 months of vaccination, such as headaches, fever or chills, widespread muscle/joint pain and rash, among others. Respondents also reported whether they experienced postvaccine flares of existing systemic rheumatic disease (lasting >2 days) and if these flares required treatment modifications.

Survey dissemination

The English language version of the survey was launched globally on 2 April 2021. Translations in Italian and Hebrew were added on 5 April 2021. We employed a convenience sampling strategy with patient partners leading survey dissemination. International patient organisations received images, text and survey links designed to explain the survey’s purpose, and disseminated the survey to their members. Additionally, the survey was publicly accessible from the C19-GRA website ( and disseminated via social media by GRA members and patient organisations. The full survey is included in the online supplemental materials.

Statistical analysis

Descriptive statistics, including means and SD, proportions and 95% CIs, were reported. All analyses were performed using R V.4.1.0.


Demographics and clinical characteristics

Between 2 April and 30 April 2021, 2860 adults with systemic rheumatic disease who received at least one dose of a COVID-19 vaccine participated in the survey (see figure 1 for flow diagram of analysed sample). The mean (SD) age of participants was 55.3 (14.3) years, 2480 (86.7%) were female and 2469 (86.3%) self-identified as white. Most participants (1603, 56.1%) were from the Americas (USA n=1366, Canada n=200 and Latin America n=37), followed by respondents from the European region (UK n=935, and rest of Europe n=252). Demographics and clinical characteristics of respondents are shown in table 1.

Figure 1

Flow diagram illustrating the analysed sample.

Table 1

Demographics and clinical characteristics of the COVID-19 Global Rheumatology Vaccine Survey respondents who received COVID-19 vaccination (n=2860)

Rheumatoid arthritis (RA) (1209, 42.3%) was the most common systemic rheumatic disease reported among participants, followed by inflammatory myositis (487, 17.0%), Sjögren’s syndrome (438, 15.3%), systemic lupus erythematosus (391, 13.7%) and spondyloarthritis (256, 9.0%). Use of systemic glucocorticoids and NSAIDs was reported by 762 (26.6%) and 740 (25.9%), respectively. The most used DMARDs were methotrexate (855, 29.9%), antimalarials (733, 25.6%) and other conventional synthetic DMARDs (510, 17.8%). Tumour necrosis factor (TNF) inhibitors were the most used biologic DMARD (bDMARD) (493, 17.2%), and 520 (18.2%) of patients reported not taking any DMARD.

The most reported comorbidities were hypertension (912, 31.9%), lung disease (736, 25.7%) and obesity (673, 23.5%). The most received COVID-19 vaccine was the Pfizer-BioNTech vaccine (1522, 53.2%), followed by Oxford-AstraZeneca (645, 22.6%), Moderna (610, 21.3%) and Janssen/Johnson & Johnson (50, 1.7%). Few respondents received other vaccines (33, 1.2%).

Communication with healthcare providers regarding COVID-19 vaccination

Most participants (2341, 81.9%) had discussed COVID-19 vaccination with their healthcare provider. Participants reported contacting their healthcare provider to discuss COVID-19 vaccination (1775, 62.1%), having the healthcare provider contact them (1349, 47.2%) and/or having a discussion regarding vaccines during a clinical visit (1817, 63.5%) (table 2). Of all respondents who discussed vaccination with their healthcare provider, 2238/2341 (95.6%) reported that vaccination was recommended, while 42 (1.8%) answered that their provider was unsure, and 10 (0.4%) reported a provider recommendation against vaccination. Most patients (2065, 88.2%) were satisfied with the conversation with their clinician, while only a minority were dissatisfied (66, 2.8%) or neither satisfied nor dissatisfied (210, 9.0%).

Table 2

Communication with healthcare providers regarding COVID-19 vaccination

Medications and COVID-19 vaccination

Most participants (1911, 66.8%) agreed with temporarily discontinuing their medications to improve vaccine effectiveness, while 472 (16.5%) disagreed and 477 (16.7%) reported being unsure. Concern for flare of systemic rheumatic disease after receiving the vaccine was reported in 1267 (44.3%) respondents, while 1009 (35.3%) were not concerned, and 584 (20.4%) were unsure.

When asked about the specific medications that participants reported taking for the treatment of their systemic rheumatic disease, the majority were willing to discontinue these medications due to COVID-19 vaccination (figure 2; online supplemental table). For participants taking methotrexate, 700/855 (81.9%) were willing to stop, with only 59 (6.9%) not willing to stop. For other medications recommended by the ACR to be modified around COVID-19 vaccination (eg, NSAIDs, mycophenolate, abatacept, rituximab, JAK inhibitors), the majority of respondents were willing to discontinue temporarily. Among participants taking systemic glucocorticoids, fewer (375/762, 49.2%) were willing to stop, 246 (32.3%) were not willing to stop and 141 (18.5%) were unsure.

Figure 2

Willingness to temporarily or permanently discontinue medications when receiving the COVID-19 vaccine. IL, interleukin; NSAIDs, non-steroidal anti-inflammatory drugs; csDMARDs, conventional synthetic drug modifying antirheumatic drugs; JAK, Janus kinase inhibitors; TNF, tumour necrosis factor; IVIG, intravenous immunoglobulin. *Includes apremilast, azathioprine, 6-mercaptopurine, leflunomide and sulfasalazine. †Includes calcineurin inhibitors (ciclosporin, tacrolimus), cyclophosphamide, thalidomide and lenalidomide. ‡Includes belimumab, IL-1 inhibitors (anakinra, canakimumab, rilonacept), IL-6 inhibitors (tocilizumab, sarilumab, siltuximab), IL-12/IL-23 inhibitors (ustekinumab, guselkumab), IL-17 inhibitors (secukinumab, ixekizumab), eculizumab, mepolizumab and vedolizumab.

Finally, when asked about actual medication discontinuation, most patients who reported taking any prescription medication (1875/2644, 70.9%) answered that they did not temporarily stop or discontinue any of their rheumatic medications before or after receiving the COVID-19 vaccine, while a minority decided to change their medication use (764, 28.9%). Only five (0.2%) patients were not sure if they had made any changes to their medication use.

Systemic rheumatic disease flare was the most frequently reported concern regarding holding or stopping antirheumatic medications (table 3). In participants taking systemic glucocorticoids, disease flares were the most frequently reported concern (443/762, 58.1%) followed by withdrawal effects (188, 24.7%). Disease flare was the most common concern among patients on all other medications. ‘No concerns’ was the second most frequent response for people receiving all other medications, except for TNF inhibitors and other bDMARDs where ‘concern for rheumatic medication may not work as well’ (73/494, 14.8% and 21/206, 10.2%, respectively) was reported.

Table 3

Concerns about medication discontinuation around COVID-19 vaccination

COVID-19 vaccination-associated adverse events

Among all participants, 1371/2860 (47.9%) participants reported at least one adverse event lasting for at least 2 days post-COVID-19 vaccine (table 4). Fatigue or sleepiness (955, 33.4%) was the most common reported adverse event, followed by headache (792, 27.7%), and widespread muscle/joint pains (653, 22.8%). There were only six (0.2%) episodes of self-reported anaphylaxis. Flares of existing systemic rheumatic disease, lasting at least 2 days post-COVID-19 vaccine, were reported by 382 (13.4%) of participants, with 132 (4.6%) requiring a new or increased dose of medication to treat the flare. The frequency of adverse events and flares of disease were similar across vaccine types.

Table 4

Adverse events and disease flares after COVID-19 vaccination, reported by patients to be severe and lasting at least 2 days


This is the largest international survey of patient perceptions and outcomes related to COVID-19 vaccines among vaccinated people with systemic rheumatic diseases. Almost all participants who discussed vaccination with a provider were recommended to receive a COVID-19 vaccination and respondents were overall satisfied with COVID-19 vaccine-related conversations with their clinicians. The majority were willing to discontinue their medications to improve vaccine response, although many remained concerned about systemic rheumatic disease flares. Although 1 in 8 reported a flare of disease after vaccination, fewer than 1 in 20 required a change in treatment. While these findings have been reassuring regarding communication with physicians regarding vaccination recommendations, individuals with systemic rheumatic disease remain concerned about the side effects of vaccines, and the risk of flares associated with vaccination, particularly around holding antirheumatic medications.

People with systemic rheumatic disease represent a subgroup for whom general population data may not apply. Potential concerns include reduced immunogenicity of vaccines related to either the underlying condition or the use of antirheumatic medications; and vaccines causing worsened adverse events or flares of their underlying rheumatic diseases.2 In an international survey of 1531 individuals with rheumatic disease conducted in December 2020, for instance, 32% reported uncertainty around vaccination,3 which may in part be driven by these concerns.

Rheumatologists have a prominent role in communicating risks and benefits of vaccination. Prior surveys of people with systemic rheumatic diseases have highlighted limited communication with rheumatologists or other healthcare providers, especially about medication changes.9–11 Other studies have cited lack of a recommendation from a treating physician for vaccination hesitancy.12–15 Among the vaccinated population in our study, there was a high frequency of communication with clinicians about the COVID-19 vaccines, and respondents were generally very satisfied. A key factor is the timing of our survey during global vaccination efforts versus other surveys that were completed prior to the availability of the COVID-19 vaccine. Another factor is that our study sample was limited to those who were vaccinated, so good communication with healthcare providers over vaccine recommendations is unsurprising.

Whether to hold antirheumatic medications for vaccination, and for how long, remains unclear for many medication classes. Hypothetical concerns about reduced immunogenicity have recently been corroborated by antibody titre studies.16 17 Recommendations from the ACR, for instance, have reflected these concerns. Initial guidance in February of 2021 recommended holding methotrexate, JAK inhibitors, abatacept and rituximab in certain patients with controlled disease6; an April 2021 update also included mycophenolate mofetil.18 These guidelines were based on limited data, including one randomised controlled trial of methotrexate holding for influenza vaccination in patients with RA,19 and two studies of holding tofacitinib in patients with RA.20 Our survey found that most patients would be willing to temporarily discontinue their medications but had concerns about a flare of their systemic rheumatic disease. As expected, current glucocorticoid users had an especially high frequency of respondents who were less willing to hold these medications. This may be explained by prior experience of flares when stopping or lowering dose of glucocorticoids, concerns about adrenal insufficiency or a relationship between glucocorticoid use and active disease. However, despite reported willingness, only a minority of participants discontinued any medication around COVID-19 vaccination. Future studies are needed to firmly establish an evidence base for temporarily holding specific antirheumatic therapies to enhance vaccine efficacy while balancing risk for disease flare.

The degree to which vaccination in general and the COVID-19 vaccinations in particular cause flares of rheumatic diseases has been a principal concern.21 Prior to the COVID-19 pandemic, a study in the UK Clinical Practice Research Database found no increased risk of flare after influenza vaccination among people with autoimmune inflammatory rheumatic disease.22 In a small study, RA disease activity remained stable following hepatitis B vaccination.23 Conversely, an internet-based case-crossover study of patients with confirmed gout found twofold higher odds for gout flares after any patient-reported vaccination.24 Similar to the rates reported in trials in the general population, a minority of patients in our study reported systemic reactions to vaccination, which included fatigue, fever and pain. Systemic rheumatic disease flares requiring a change in medication, however, were uncommon. These data align with a large, physician-reported registry supported by EULAR COVID-19 database.25 Between 5 February and 27 April 2021, clinicians reported 1519 patients with rheumatic disease who had received COVID-19 vaccination, the majority (83%) of whom received an mRNA-based vaccine. Overall, 31% had potential vaccine-related side effects; 5% had flares of their underlying systemic rheumatic disease, 1.2% of which were reported as severe. In two prospective cohorts of patients with systemic rheumatic disease followed after COVID-19 vaccination, disease activity remained stable.26 27 The complementary findings from these two studies provide reassuring evidence regarding safety and reactogenicity of COVID-19 vaccination among a systemic rheumatic disease population.

Strengths of our study include rapid dissemination, global reach and questions specifically addressing concerns and willingness to hold specific antirheumatic medications. Several important limitations should be acknowledged. First, selection bias may have resulted from respondents with adverse events being more likely to fill out the survey. Despite this, the frequency of systemic rheumatic disease flares requiring medication changes remained low and was overall consistent with similar registries. Second, although participants were asked “Has a doctor ever told you had any of the following rheumatologic diseases?”, report of self-diagnosis or misdiagnosis is a possibility. However, the reports of treatment with systemic immunomodulators prescribed by clinicians and the fact that the distribution of the survey through patient organisations potentially minimises this making it unlikely that this could substantially affect the results. Third, this study was limited to English, Hebrew and Italian translations of the survey and may not be generalisable to those who speak other languages or reside in other regions. Translations into other languages are ongoing and will be reported in the future. Fourth, respondents were mostly white and reported high levels of education. These results may not be applicable to addressing barriers among other racial or ethnic groups or among other socioeconomic groups.28–30 Fifth, at the time of the survey, geographic variation in vaccine availability and access resulted in a preponderance of UK and US respondents. Sixth, the timing of our survey coincided with the Centers for Disease Control and Food and Drug Administration pause on the Janssen/Johnson & Johnson vaccine,31–33 which limited the number of responses from those who had received this vaccine. Seventh, some conditions such as inflammatory myositis may be over-represented in our cohort, due to the registries and patient advocacy groups to which our survey was disseminated most easily. Finally, this was a descriptive analysis and inferential statistics were intentionally not performed.


This study presents encouraging data regarding communication between people with systemic rheumatic diseases and their physicians and to the overall safety of COVID-19 vaccination in this patient population. Reassuringly, significant flares requiring changes in medications were relatively infrequent. Clinicians should maintain awareness of changing guidelines as further data become available to provide continued communication and patient counselling regarding risks and benefits of vaccination. Future studies should assess the degree to which vaccine immunogenicity and reactogenicity among individuals with systemic rheumatic disease differ compared with the general population. Further knowledge about barriers to vaccination in different racial and ethnic groups among patients living with systemic rheumatic diseases is needed.

Data availability statement

Data are available on reasonable request. Researchers interested in performing additional analyses from survey data are invited to submit proposals through the COVID-19 Global Rheumatology Alliance at For approved projects, we will be able to provide summary tables and data analyses as requested. We do not currently have IRB approval to make the raw data available to other researchers.

Ethics statements

Patient consent for publication

Ethics approval

The study was deemed exempt from full review by the Boston Children's Hospital institutional review board.


We would like to thank Saskya Angevare, Richard P Beesley, Eugenia Chock, Berk Degirmenci, Christele Felix, Shangyi Jin, Elsa Mateus, Andrea Peirce, Esra Sari, Robert Tseng, Leslie Wang and Erick Adrian Zamora for their invaluable contributions to the GRA Vaccine Survey.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • JSH, JFS and JAS are joint senior authors.

  • SES and JWL are joint first authors.

  • Twitter @SattuiSEMD, @mugartegil, @pedrommcmachado, @philipcrobinson

  • JSH, JFS and JAS contributed equally.

  • SES and JWL contributed equally.

  • Contributors SES, JL, KK, ES and MP contributed to data collection, data quality control, data analysis and interpretation. They drafted and revised the manuscript critically for important intellectual content and gave final approval of the version published. AA, DA-R, FB, IB, RC, ADS, ED, KD, TAG, CLH, RAH, BFH, EH, LEK, AK, AHK, DFLL, CL BM, SM, MN, JASi, NS, MFU-G, JW and KJY critically revised the manuscript and provided intellectual content. TTM, CH, MLarche, MLevine, GF, LT and LGR contributed to planning and data collection, reviewed the manuscript and provided important intellectual content. SB, WC, RG, PMM, PCR, PS, ZW and JY contributed to the acquisition, analysis and interpretation of the data. They drafted and revised the manuscript critically for important intellectual content and gave final approval of the version published. JAS, JS and JH directed the work, designed the data collection methods and contributed to the analysis and interpretation of the data. They drafted and revised the manuscript critically for important intellectual content and gave final approval of the version to be published. SES, JWL, KK, JSimard and JSparks had full access to the data and verify the credibility of the underlying data. All authors have read, revised and approved this manuscript and final responsibility for the decision to submit for publication.

  • Funding This study was supported by the European Alliance of Associations for Rheumatology and American College of Rheumatology Research and Education Foundation. Dr. Lisa Rider's involvement was supported in part by the Intramural Research Program of the National Institutes of Health, National Institute of Environmental Health Sciences.

  • Disclaimer The views expressed here are those of the authors and participating members of the COVID-19 Global Rheumatology Alliance and do not necessarily represent the views of the American College of Rheumatology (ACR), EULAR, the (UK) National Health Service (NHS), the National Institute for Health Research (NIHR) or the (UK) Department of Health, or any other organisation. The funders had no role in the decision to publish or preparation of this manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard University, its affiliated academic health care centers, or the National Institutes of Health.

  • Competing interests SES has received funding from the Vasculitis Foundation and the Vasculitis Clinical Research Consortium unrelated to this work. JL has received research grant funding from Pfizer unrelated to this work. ES is a Board Member of the Canadian Arthritis Patient Alliance, a patient run, volunteer-based organisation whose activities are primarily supported by independent grants from pharmaceutical companies. MP was supported by a Rheumatology Research Foundation Scientist Development grant. DA-R is a Scientific Advisor for GlaxoSmithKilne unrelated to this work. FB reports personal fees from Boehringer, Bone Therapeutics, Expanscience, Galapagos, Gilead, GSK, Merck Sereno, MSD, Nordic, Novartis, Pfizer, Regulaxis, Roche, Sandoz, Sanofi, Servier, UCB, Peptinov, TRB Chemedica and 4P Pharma outside of the submitted work. No funding relevant to this manuscript. RC: speakers bureau for Janssen, Roche, Sanofi, AbbVie. KD reports no COI-unpaid volunteer president of the Autoinflammatory Alliance. Any grants or funding from pharma is received by the non-profit organisation only. CLH received funding under a sponsored research agreement unrelated to the data in the paper from Vifor Pharmaceuticals. LeK has received a research grant from Lilly unrelated to this work. AHJK participated in consulting, advisory board or speaker's bureau for Alexion Pharmaceuticals, Aurinia Pharmaceuticals, Annexon Biosciences, Exagen Diagnostics and GlaxoSmithKilne and received funding under a sponsored research agreement unrelated to the data in the paper from GlaxoSmithKline. JSingh has received consultant fees from Crealta/Horizon, Medisys, Fidia, PK Med, Two Labs, Adept Field Solutions, Clinical Care Options, Clearview Healthcare Partners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, Jupiter Life Science, UBM, Trio Health, Medscape, WebMD and Practice Point Communications; and the National Institutes of Health and the American College of Rheumatology. JSingh owns stock options in TPT Global Tech, Vaxart Pharmaceuticals and Charlotte’s Web Holdings. JSingh previously owned stock options in Amarin, Viking and Moderna Pharmaceuticals. JSingh is on the speaker’s bureau of Simply Speaking. JSingh is a member of the executive of Outcomes Measures in Rheumatology (OMERACT), an organisation that develops outcome measures in rheumatology and receives arms-length funding from eight companies. JSingh serves on the FDA Arthritis Advisory Committee. JSingh is the chair of the Veterans Affairs Rheumatology Field Advisory Committee. JSingh is the editor and the Director of the University of Alabama at Birmingham (UAB) Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis. NSingh is supported by funding from the Rheumatology Research Foundation Investigator Award and the American Heart Association. MFU-G has received research support from Pfizer and Janssen, unrelated to this work. SB reports personal fees from Novartis, AbbVie, Pfizer and Horizon Pharma, outside the submitted work. RG reports personal fees from AbbVie New Zealand, Cornerstones, Janssen New Zealand and personal fees and non-financial support Pfizer New Zealand (all <US$10 000) outside the submitted work. PMM reports personal fees from AbbVie, Eli Lilly, Janssen, Novartis, Pfizer and UCB, grants and personal fees from Orphazyme, outside the submitted work. PCR reports personal fees from AbbVie, Gilead, Lilly and Roche, grants and personal fees from Novartis, UCB Pharma, Janssen and Pfizer and non-financial support from BMS, outside the submitted work. PS reports honoraria from Social media editor for @ACR_Journals, outside the submitted work. ZSW reports grants from NIH, BMS and Principia/Sanofi and personal fees from Viela Bio and MedPace, outside the submitted work. JY reports personal fees from Pfizer and Eli Lilly, and grants and personal fees from AstraZeneca, outside the submitted work. MJL reports grants from American College of Rheumatology, during the conduct of the study and consulting fees from AbbVie, Amgen, Actelion, Boehringer Ingelheim, BMS, Celgene, Gilead, J&J, Mallinckrodt, Novartis, Pfizer, Roche, Sandoz, Sanofi, Sobi and UCB, outside the submitted work. LGR was supported by the Intramural Research Program of the National Institute of Environmental Health Sciences (NIEHS; ZIAES101074) of the National Institutes of Health. JH reports grants from Childhood Arthritis and Rheumatology Research Alliance (CARRA) and Rheumatology Research Alliance, and personal fees from Novartis, Pfizer and Biogen, outside the submitted work. JSimard received research grant funding from the National Institutes of Health unrelated to this work (NIAMS: R01 AR077103 and NIAID R01 AI154533). JSparks has performed consultancy for AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Inova Diagnostics, Optum and Pfizer unrelated to this work.

  • Provenance and peer review Not commissioned; externally peer reviewed.