The decision to use vaccines in children with rheumatic diseases must be guided by what ongoing therapy they are on, with an eye to timing the vaccination before initiation of particularly immunosuppressive treatments when possible. Follow-up titers should be assessed in some cases to document that the child has mounted a protective response, according to guidelines issued by a task force convened by the European League Against Rheumatism.
These are among the recommendations on use of vaccines in children with rheumatic diseases that the panel made after a systematic literature review of MEDLINE in December 2009, MEDLINE and EMBASE in November 2010, and abstracts from EULAR and American College of Rheumatology meetings in 2008 and 2009 (Ann. Rheum. Dis. 2011 Aug. 3 [doi:10.1136/ard.2011.150193]).
Lead by Dr. M.W. Heijstek of Wilhelmina Children’s Hospital, University Medical Center, Utrecht, the task force reviewed 67 papers, combining the search terms "vaccinations" with "immunosuppressive drugs" and 147 papers using "vaccinations" and "pediatric autoinflammatory or rheumatic disease."
Their first set of guidelines address vaccination in children on immunosuppressive medications:
• Pediatric patients who use glucocorticosteroids, disease-modifying antirheumatic drugs (DMARDs), and/or anti–tumor necrosis factor-alpha (anti-TNF-alpha) therapy can receive nonlive vaccines, when indicated according to national guidelines.
• Clinicians should determine pathogen-specific antibody concentrations after vaccination in patients who are taking either high-dose glucocorticosteroids (daily dose of 2 mg/kg higher or a total dose of at least 20 mg/day for 2 weeks or more) or rituximab and possibly in patients using an anti–TNF-alpha agent.
• The pneumococcal or influenza vaccine should be given before patients initiate treatment with rituximab.
• Tetanus immunoglobulin is indicated when patients who have been taking rituximab within the past 6 months develop a contaminated wound.
• Physicians should determine pneumococcal serotype–specific antibody concentrations after pneumococcal polysaccharide vaccine 23 vaccination in patients on methotrexate at the time of vaccination.
The panel also developed recommendations for use of live attenuated and nonlive composite vaccines in pediatric patients with rheumatic disease. For live attenuated vaccines, the panel recommends that clinicians:
• Withhold them in patients using high-doses of DMARDs or glucocorticosteroids or biological agents.
• Adhere to national vaccination guidelines for live-attenuated vaccines in patients unless they are are on high-dose DMARD, high-dose glucocorticosteroids or biological agents.
• Consider booster vaccinations against varicella zoster virus (VZV); measles, mumps and rubella (MMR); and yellow fever in patients using less than 15mg/m2 methotrexate per week or low-dose glucocorticosteroids.
• Withhold bacillus Calmette-Guerin (BCG) vaccination during active Kawasaki disease.
• Assess VZV infection and vaccination history, especially in those patients likely to use high-dose immunosuppressive therapy or biological agents. In history is negative for VZV infection or vaccination, consider using the vaccine before initiating immunosuppressive therapy.
In the case of non-live composite vaccines, the guidelines recommend that clinicians:
• Administer the tetanus toxoid (TT) vaccine to patients with juvenile systemic lupus erythematosus (SLE) and juvenile idiopathic arthritis (JIA) according to national vaccination guidelines.
• Adhere to national vaccination guidelines for vaccination against the following: hepatitis A and B viruses, tetanus, diphtheria, pertussis, Haemophilus influenzae type B (Hib), pneumococci and meningococci, cholera, Japanese and tickborne encephalitis, poliovirus, rabies, encephalitis, typhoid fever, and human papillomavirus (HPV).
• If vaccinations against Hib, pneumococci, and meningococci are not included in the national vaccination programs, these vaccinations are recommended for children with rheumatic diseases who have low complement levels or functional asplenia. These vaccinations can be considered in patients on high-dose immunosuppressive drugs or biologic agents before therapy.
• Vaccinate female patients with SLE against HPV during adolescence, as they are at higher risk for HPV, but remain vigilant for potential thromboembolic events.
• Consider annual influenza vaccination in all pediatric patients with rheumatic disease.
The recommendations often refer to national vaccination guidelines, which consider local epidemiology, programmatic issues, resources, and policies, the authors say.
"Generally, the immunogenicity of vaccines is good in [children with rheumatic diseases]," they added. "There are some exceptions, depending on the type of dose of immunosuppressive treatment and type of vaccine."
The researchers also studied disease activity and adverse events. Most studies were underpowered to assess safety, they say, meaning that additional safety studies are warranted.
Finally, the authors recommend that these guidelines be updated regularly as new evidence on vaccinating pediatric patients on immunomodulating drugs becomes available.
The authors have no conflicts to disclose. The study was funded by EULAR.