TNF and rheumatoid arthritis: A recent meta-analysis suggested that anti-TNF treatment alone has no significant negative impact on the response to PPSV23, while patients receiving a TNF inhibitor plus methotrexate (MTX) seem to have impaired immune responses to PPSV23.6 Infections with S. pneumoniae are a major cause of mortality and morbidity throughout the world.7 Guidelines indicate that vaccination with PPSV23 should be considered in RA patients treated with biologics.8 However, the use of immunosuppressive therapies can reduce the response to vaccination.