Spring 2014 (Volume 24, Number 1)
Vaccination in Juvenile Rheumatic Diseases
By Suzanne E. Ramsey, MD, FRCPC
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A three-year-old presents with juvenile idiopathic arthritis (JIA). A 14-year-old with systemic lupus erythematosus (SLE) on prednisone has functional asplenia. A 17-month-old patient has received intra-venous immunoglobulin (IVIG) for Kawasaki disease. A 10-year-old with juvenile dermatomyositis has just disc-ontinued IVIG and methotrexate (MTX). What vaccine issues must be addressed in these patients?
Dr. Ramsey is a well-respected clinician-educator in the field of pediatric rheumatologic diseases.
With many new immunosuppressive therapies and evolving provincial immunization schedules1-4 we review our guidelines annually with our vaccinology colleagues and make reference to international guidelines.5 Routine inactivated vaccines should be brought up-to-date. Live virus vaccines are generally considered contraindicated in immunosuppressed children and should be given before escalating treatment or when there is a gap in immunosuppression. High dose steroids (prednisone 10 mg/d-20mg/d or 0.2 mg/kg/d for more than two weeks), disease modifying anti-rheumatic drugs (DMARDs), and biologics may reduce vaccine response, as may active inflammatory disease. Systemic corticosteroids are one of the greatest risk factors for infection in rheumatology patients;6 DMARDs and biologics impact infection risk variably and require further study.
Viral Vaccines
Vaccination to ensure two doses of the measles, mumps, rubella, and varicella (MMRV) vaccine should be considered early in a child’s life. MMRV can be given as early as 12 months and repeated within three months.1 This vaccine may be safe in JIA patients on low dose MTX
(< 10 mg/m2) but its safety has not been established during more intensive therapies.7 Limited data exist on varicella zoster virus (VZV) vaccine safety in rheumatology patients. Extrapolation from children with hematologic malignancy is difficult given that rheumatologic immunosuppression is typically chronic. Indeterminate VZV or negative hepatitis B serology in previously vaccinated patients may improve with an additional booster.2,3 Secondary prophylaxis for VZV may be necessary. Rheumatology patients may benefit from personal and household annual influenza vaccines. Cold-adapted live flu vaccine (nasal mist) is more effective than injected inactivated vaccine; however, there is no safety data in immunocompromised children. Vaccination of siblings should be safe unless the patient is considered profoundly immunosuppressed, in which case live vaccines should be avoided for household contacts.2 Live vaccines are delayed in children treated with IVIG, as it typically contains inactivating levels of MMR and VZV antibody. Specifically, MMRV vaccines for Kawasaki disease patients must be delayed for 11 months after treatment with high-dose IVIG (2 gm/kg). Lower doses of IVIG and other blood products require a lesser delay.1 Plans for international travel should trigger consultation with a Public Health or a Travel Medicine consultant, as travel vaccines such as yellow fever and oral typhoid are contraindicated in immunosuppressed patients.1
Bacterial Vaccines
Gram-positive infections may add to morbidity and mortality. Unvaccinated children should receive pneumococcal vaccines, although the ideal timing in the disease course is unclear. Guidelines for previously unvaccinated immunocompromised children are pneumococcal conjugate vaccine (PCV) (e.g., Prevnar®13) followed no sooner than eight weeks by pneumococcal polysaccharide vaccine (PPSV)
(e.g., Pneumovax® 23).1 Patients with surgical or autoimmune splenectomy require special consideration and pneumococcal, hemophilus influenza, and meningococcal vaccine are all recommended prior to planned splenectomy followed by pneumococcal antibiotic prophylaxis.8
Further Considerations
Following the cessation of immunosuppression, a protocol should be established for each child. While a remote risk of disease flare or adverse event may exist with vaccination, risk-benefit ratios typically strongly favour immunization. It is generally accepted, however, that a vaccine should be avoided if it has precipitated a disease flare or with highly active disease.2
References
1. Canadian Immunization Guide. Available from: www.phac-aspc.gc.ca/publicat/cig-gci/
2. Silva CA, Aikawa NE, Bonfa E. Vaccinations in Juvenile Chronic Inflammatory Disease: An Update. Nat Rev Rheumatol 2013; 9(9):532-43.
3. Heijstek MW, Ott de Bruin LM, Bijl M, et al. EULAR Recommendations for Vaccination in Pediatric Patients with Rheumatic Diseases. Ann Rheum Dis 2011; 70(10):1704-12.
4. Le Saux N. Biologic Response Modifiers to Decrease Inflammation: Focus on Infectious Risks. Paediatr Child Health 2012; 17(3):147-50.
5. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host. Clin Infect Dis 2014; 58(3):309-18.
6. Beukelman T, Xie F, Chen L, et al. Rates of Hospitalized Bacterial Infection Associate with Juvenile Idiopathic Arthritis and its Treatment. Arthritis Rheum 2012; 64(8):2773-80.
7. Heijstek HW, Pileggi GC, Zonneveld-Huijsson E. Safety of Measles, Mumps and Rubella Revaccination in Children with Juvenile Idiopathic Arthritis. Ann Rheum Dis 2007; 66(10):1384-7.
8. Price VE, Dutta S, Blanchette VS, et al. The Prevention and Treatment of Bacterial Infections in Children with Asplenia or Hyposplenia: Practice Considerations at the Hospital for Sick Children. Pediatr Blood Cancer 2006; 46(5):597-603.
Suzanne E. Ramsey, MD, FRCPC
Associate Professor of Pediatrics
Pediatric Rheumatologist
IWK Health Centre,
Dalhousie University
Halifax, Nova Scotia |
