EULAR/PRES recommendations for vaccination of paediatric patients with autoimmune inflammatory rheumatic diseases: update 2021

Abstract

ObjectivesRecent insights supporting the safety of live-attenuated vaccines and novel studies on the immunogenicity of vaccinations in the era of biological disease-modifying antirheumatic drugs in paediatric patients with autoimmune/inflammatory rheumatic diseases (pedAIIRD) necessitated updating the EULAR recommendations.MethodsRecommendations were developed using the EULAR standard operating procedures. Two international expert committees were formed to update the vaccination recommendations for both paediatric and adult patients with AIIRD. After a systematic literature review, separate recommendations were formulated for paediatric and adult patients. For pedAIIRD, six overarching principles and seven recommendations were formulated and provided with the level of evidence, strength of recommendation and Task Force level of agreement.ResultsIn general, the National Immunisation Programmes (NIP) should be followed and assessed yearly by the treating specialist. If possible, vaccinations should be administered prior to immunosuppressive drugs, but necessary treatment should never be postponed. Non-live vaccines can be safely given to immunosuppressed pedAIIRD patients. Mainly, seroprotection is preserved in patients receiving vaccinations on immunosuppression, except for high-dose glucocorticoids and B-cell depleting therapies. Live-attenuated vaccines should be avoided in immunosuppressed patients. However, it is safe to administer the measles–mumps–rubella booster and varicella zoster virus vaccine to immunosuppressed patients under specific conditions. In addition to the NIP, the non-live seasonal influenza vaccination should be strongly considered for immunosuppressed pedAIIRD patients.ConclusionsThese recommendations are intended for paediatricians, paediatric rheumatologists, national immunisation agencies, general practitioners, patients and national rheumatology societies to attain safe and effective vaccination and optimal infection prevention in immunocompromised pedAIIRD patients.

Efficacy, Immunogenicity and Safety of Vaccination in Pediatric Patients With Autoimmune Inflammatory Rheumatic Diseases (pedAIIRD): A Systematic Literature Review for the 2021 Update of the EULAR/PRES Recommendations

“…Twenty-five patients from one study had been previously described in a study by Pileggi et al ( 71 ). Additionally, 3 studies evaluated the MMR/V vaccine in 602 patients with pedAIIRD ( 56 , 57 , 72 ). For clarity, we distinguish between the studies on primo varicella vaccination in VZV naïve patents and the varicella booster vaccine.…”

“…Efficacy data were not available and immunogenicity was not studied systematically, the studies focussed on safety of vaccination. In 10 patients who received the MMR booster and the MMR/V vaccination 1 case of varicella zoster was reported, but there were no severe vaccination-induced MMR infections ( 59 , 72 ). In patients with periodic fever syndromes on IL-1 blocking agents, vaccinations (tetanus, influenza, PCV) were well tolerated, accept for the PPSV23 vaccine that caused severe adverse events in patients with CAPS.…”

Real-life vaccination coverage in Slovak children with rheumatic diseases

“…. and for adults (2019) with rheumatic diseases (RD), liveattenuated vaccines are no longer contraindicated during IST and especially booster doses of MMR and varicella zoster virus (VZV) vaccination may be considered with caution during low-grade immunosuppression (19,20). This is an important change, not only in the context of recent measles outbreaks in Europe and the United States, but also because of increased migration related to the war in Ukraine, as up to 75% of all measles cases in Europe were reported from Ukraine in 2019 (29-31).…”

“…Until recently, due to concerns about potential infection with vaccination strains, contraindication of live-attenuated vaccines during high-dose IST was considered standard of care (18). In the light of currently available evidence, vaccinations with live-attenuated vaccines can be considered with caution under special circumstances even during low-dose immunosuppression (19,20), with emerging data supporting this approach also in children treated for PRDs, including treatment with biologics (21,22).…”

“…Evidence-based recommendations for the vaccination of patients with PRDs are available (19,23). However, their degree of implementation into practice remains suboptimal or even unknown (10)(11)(12)(13)(14).…”