• Chuanhui Xu, Manjari Lahiri, Amelia Santosa, Li-Ching Chew, Stanley Angkodjojo, Melonie Sriranganathan, Warren Fong, Thaschawee Arkachaisri, Ernest Suresh, Kok Ooi Kong, Aisha Lateef, Tau Hong Lee, Keng Hong Leong, Andrea Low, Teck Choon Tan, and Ying-Ying Leung.
• Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore.
• Singapore Med J. 2023 Jul 27.

IntroductionThis review aims to provide evidence-based recommendations for an enhanced primary series (third dose) coronavirus disease 2019 (COVID-19) vaccination in people with rheumatic diseases (PRDs) in the local and regional context.MethodsLiterature reviews were performed regarding the necessity, efficacy, safety and strategies for enhanced primary series COVID-19 vaccination in PRDs. Recommendations were developed based on evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence was synthesised by eight working group members, and the consensus was achieved by a Delphi method with nine members of an expert task force panel.ResultsTwo graded recommendations and one ungraded position statement were developed. PRDs have impaired immunogenicity from the COVID-19 vaccine and are at an increased risk of postvaccine breakthrough severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and poor clinical outcomes, compared to the general population. We strongly recommend that PRDs on immunomodulatory drugs be offered a third dose of the messenger RNA (mRNA) vaccine as part of an enhanced primary series, after the standard two-dose regimen. We conditionally recommend that the third dose of mRNA vaccine against SARS-CoV-2 be given at least 4 weeks after the second dose or as soon as possible thereafter. There is insufficient data to inform whether the third mRNA vaccine should be homologous or heterologous in PRDs.ConclusionThese recommendations that were developed through evidence synthesis and formal consensus process provide guidance for an enhanced primary series COVID-19 vaccination in PRDs.

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