Vaccination of Children and Adolescents With Rheumatic Diseases

Laura Dell'Era; Susanna Esposito; Fabrizia Corona; Nicola Principi

Disclosures

Rheumatology. 2011;50(8):1358-1365. 

In This Article

Abstract and Introduction

Abstract

Children with rheumatic diseases (RDs) are at greater risk of infection because of their aberrant immunity and frequent use of immunosuppressive drugs. However, the use of vaccinations in such children is debated by many experts who think that the patients' immune response is insufficient to assure protection; some of them are also afraid that vaccines could trigger a persistent autoimmune response and lead to severe clinical problems including a relapse of the RD. This review describes the available data regarding the risks of vaccine administration, and the immunogenicity, efficacy and tolerability of the vaccines usually recommended for children with RDs. The data not only show that the schedule suggested for otherwise healthy children should be followed, but also that pneumococcal and influenza vaccinations should be strongly recommended because of the known risk of severe infections in patients with RD. However, there are areas in which further research is urgently required.

Introduction

Children with rheumatic diseases (RDs) are at greater risk of infection than age- and gender-matched subjects without RD because of their aberrant immunity and frequent use of immunosuppressive drugs.[1] They are also significantly more likely to experience infections requiring hospitalization, including septicaemia and pneumonia.[2]

The recent introduction of anti-TNF treatments has contributed to changing the pattern of infections in RD patients. It has been reported that common infections, such as upper respiratory tract infections, are frequent adverse events and reasons for withdrawal of anti-TNF therapy in clinical trials and observational studies.[3,4] There have also been case reports of serious infections due to Streptococcus pneumoniae during therapy, including pneumonia, severe pneumonia, necrotizing fasciitis and fatal septicaemia.[3,4] The use of anti-TNF therapy has also been identified as a risk factor for tuberculosis and opportunistic infections associated with a dysregulated Th1 response.[5,6] Moreover, escalating treatment regimens mean that many patients are on their second or third consecutive biological treatment for RD, and this could modify immune defence (i.e. suppression of T and B cells) and lead to increased risks of infectious diseases.[7,8] Finally, a number of children with RD also have other risk factors for infection, such as central lines.[2]

The possibility of preventing various infectious diseases by administering the vaccines routinely given to normal children should, therefore, lead to the systematic vaccination of subjects with RD. However, this is questioned by many experts on the grounds that the patients' immune response is impaired by immunosuppressive drugs and does not induce seroprotective antibodies; some of them are also afraid that vaccines could trigger a persistent autoimmune response and lead to severe clinical problems including a relapse of RD.[9,10] Consequently, many children with RD do not receive the vaccinations usually recommended by health authorities for healthy children.[11]

This review describes the available data regarding the risks of vaccine administration and the immunogenicity, efficacy and tolerability of the vaccines usually recommended for children with RDs. Its main aims are to verify whether these patients are really exposed to a substantial risk of autoimmune disease when vaccinated in the same way as healthy children, whether they can be considered protected after vaccination and whether a special vaccination schedule should be used.

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