Vaccinations for Kids with Arthritis

Vaccines are critical for preventing disease—and especially so for children with conditions like arthritis. 
“Kids with arthritis and other chronic inflammatory diseases are potentially at higher risk for infection, and so it is particularly important that they are covered with all the national recommendations in terms of immunizations,” says Dawn Wahezi, MD, MS, interim chief of pediatric rheumatology, Children’s Hospital at Montefiore Medical Center in New York.

Vaccines work by exposing the immune system to a small dose of a virus or bacteria. The immune system learns to recognize the germ and fight it off when exposed to it in the future. There have been concerns that the vaccine-triggered immune system response might cause a flare-up of inflammatory diseases like arthritis. But recent evidence suggests vaccines don’t trigger disease flares, and they shouldn’t be avoided for that reason.
Kids with arthritis can—and should—get all vaccines the CDC recommends for their age group, with just a few exceptions.

There are two main types of vaccines—live attenuated and inactivated. Live attenuated vaccines contain a live but weakened strain of a virus or bacteria. Inactivated vaccines are made from killed viruses or bacteria, or from parts of these killed diseases.

Vaccine effectiveness relies on the recipient having a healthy immune system. Many of the drugs used to treat juvenile arthritis (JA)—biologics, corticosteroids and disease-modifying anti-rheumatic drugs—relieve symptoms by suppressing the immune system so it can’t attack the joints. That’s why they’re called immunosuppressant drugs. 

Some experts have worried that an immune system weakened by immunosuppressant medicine may not mount the proper response to a vaccine. Another concern is that a live vaccine could potentially cause the disease it was designed to prevent. “Live vaccines use a small component of the actual microbes to make the vaccine, so there’s always the chance children could develop the disease,” says Julia G. Harris, MD, assistant professor of pediatrics at the University of Missouri-Kansas City School of Medicine and pediatric rheumatologist at Children’s Mercy Kansas City. “The chance is low, and there have been more studies showing that it may be safe for kids with arthritis to get some live vaccines. But right now, based on the literature that we have, we do recommend avoiding those.” 

A 2015 review of studies published in Current Rheumatology Reports found that live vaccines didn’t lead to any infections, although the authors said more research is needed to confirm that these vaccines are safe for kids with arthritis before changing the recommendations. Both the Infectious Diseases Society of America and the American College of Rheumatology recommend that people who take immune suppressing medications avoid live vaccines.

Currently, the only two live vaccines on the childhood immunization schedule are for measles, mumps, rubella (MMR) and chickenpox (varicella). The nasal flu vaccine, FluMist, is no longer recommended.

Overall, the review concluded that inactive vaccines are effective and safe for children with arthritis. Most of the children studied didn’t have any serious side effects from vaccines. Children who were taking corticosteroids, methotrexate and biologic drugs all mounted a protective immune response against the disease. However, the response waned over time in children who were taking biologics, which may indicate the need for a booster vaccine to ensure that these kids are adequately protected.

Kids with JA need their vaccinations, but the timing might have to be shifted. “Ideally, patients should be vaccinated before starting immunosuppressant therapy to ensure that they are protected,” Dr. Wahezi says. 
If that’s not possible, they may need to wait. She says once the disease is stable enough for kids to go off their medication, “We’ll use that opportunity to catch them up on vaccinations.”

Children who are on immunosuppressant drugs need to get the pneumococcal polysaccharide (PPSV23) and pneumococcal 13-valent conjugate (PCV13) vaccines. These vaccines protect against pneumococcal bacteria, which cause meningitis, pneumonia, sinusitis and ear infections. Kids taking immunosuppressant medications are at greater risk for these infections, which can sometimes be serious enough to lead to hospitalization.

Rarely will any child—even one with arthritis—need to avoid all vaccinations. Typically, they’ll just need to stay away from live vaccines if they’re on immunosuppressant drugs.
 
Skipping the live vaccines shouldn’t prevent your child from attending school as usual. Every state provides medical exemptions for vaccinations. “Typically, we can speak with the school and provide documentation that the live vaccines are contraindicated due to their medications,” Dr. Wahezi says.

Not getting a vaccine or two shouldn’t put your child at higher risk for disease—provided you take the proper precautions. Make sure all your child’s family members and close contacts are up-to-date (including yourself) on their vaccines to lower your child’s odds of being exposed to infections.

Also, encourage your child to follow good disease prevention practices, such as regular hand washing, avoiding people who are sick and staying home from school when there is an outbreak of illness, Dr. Harris advises.
If your child does get sick, see a doctor as soon as possible. Prompt treatment—for example, with antiviral drugs for the flu or chickenpox—can prevent a minor illness from becoming serious.