Vaccination of Children and Adolescents With Rheumatic Diseases

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


Rheumatology. 2011;50(8):1358-1365. 

In This Article

Vaccine Recommendations for Children with RD

Analysis of the international literature published during the past 15 years shows that there are only a few studies of immunization in children with RDs. Some vaccines have not been specifically studied at all; in other cases, the studies have involved small groups of patients with different clinical characteristics or therapies. No randomized, double-blind, controlled studies are available, and no clinical efficacy or effectiveness data relating to individual vaccines have been collected. The studies that are available show that conventional RD therapy generally has little effect on immune responses to vaccines, whereas the new biological drugs can reduce antibody production. However, this evidence is not very satisfactory because it does not make it possible to establish whether certain biological drugs reduce immune responses more than others, what doses can interfere with antibody responses or whether active disease (per se or because of the treatment it requires) justifies the deferral of vaccination. Moreover, although some case reports have suggested possible associations between vaccinations and the induction or exacerbation of autoimmune reactions, few data relate to children and they have not been confirmed by prospective investigations or thorough case–control studies. In addition, the lack of specific guidelines for children with RDs leads to discordances in clinical practice[11] and explains why about one-third of them are incompletely vaccinated.[73]

The current data and risk/benefit ratios of vaccinations are sufficient to encourage their use in children with stable RD. This recommendation applies to inactivated and recombinant vaccines, whatever the degree of immunosuppression, and all disease subgroups regardless of the treatments given. Vaccinations should be postponed only in the case of severe active RD (and then only until the child has stabilized) in order to avoid any misunderstandings related to safety issues (i.e. adverse events attributed to a vaccination but actually due to the underlying disease), and a vaccine should be avoided if it has previously caused a disease relapse. There are few data concerning the immunogenicity and safety of live attenuated vaccines in children with RD. The available evidence suggests that MMR vaccine is safe, whereas other live vaccines should not be administered in the presence of severe immunosuppression until further studies are available. Furthermore, pneumococcal and influenza vaccinations should be strongly recommended because of the increased risk of these infections associated with immunosuppressive therapy.

In conclusion, a number of areas should be covered by future research. First of all, there is an urgent need for studies of the immunogenicity, safety and efficacy of the new PCVs and adjuvanted influenza vaccines, including when they are co-administered. There is also a need for studies of HPV vaccines (usually administered after the onset of RD) as immunocompromised patients are at increased risk of HPV infection. It is essential to clarify how long vaccine-induced immunity lasts, and whether vaccinations actually protect RD patients against the respective infections. Finally, educational programmes are required for health-care workers, the patients and their families in order to guarantee adequate protection against infectious diseases in this high-risk category of subjects.


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