Vaccinations for Kids on Biologics

By Linda Rath | Feb. 2, 2026

Vaccines are an important part of keeping healthy kids healthy. But they’re even more important for children with inflammatory conditions like juvenile arthritis, especially if they take medications that suppress the immune system. Drugs such as methotrexate and biologics effectively treat arthritis, but because they affect kids’ ability to fight off germs, they also can lead to serious infections. Kids with arthritis are already at higher risk of infection as a result of the disease itself. Vaccines help reduce the risks of certain infectious diseases.

What’s Changed: Recommendations

Federal public health agencies lowered the number of recommended immunizations from 18 to 11 for children under age 18. Hepatitis A and B, rotavirus, COVID-19, flu and meningococcal vaccines were no longer included, and just one shot of human papilloma virus (HPV) vaccine is recommended instead of the usual two. Although those changes were overturned in court, many parents are uncertain about what guidelines to follow.

The American Academy of Pediatrics (AAP) — a leader in childhood vaccine recommendations — continues to recommend all 18 immunizations, based on the body of scientific evidence. Its guidelines are backed by many pediatricians and 12 top pediatric health organizations, including the American Academy of Family Physicians and American College of Obstetrics and Gynecology.

Types of Vaccines

Most vaccines work by exposing the immune system to a small dose of a virus or bacteria. Once the immune system learns to recognize the germ, it’s better able to fight it off in the future. Most of these types of vaccines are made of killed, or inactivated, viruses and bacteria and can’t cause illness. They have been proven safe for all children, even those treated with biologics. The newer vaccines used to prevent COVID-19 are messenger RNA (mRNA) vaccines, which do not contain live or inactivated virus.

Some vaccines, including those for measles, mumps, rubella (MMR), varicella (chickenpox; MMRV for the combined shot), flu (nasal spray only) and rotavirus, contain a weakened form of the live virus (called a “live attenuated virus”) — enough to create immunity but not enough to cause illness in healthy kids. Many of the drugs used to treat juvenile arthritis (JA) — biologics, corticosteroids and disease-modifying anti-rheumatic drugs, like methotrexate — 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 generally are not advised for children taking immunosuppressant drugs. Normally, live attenuated vaccines are postponed until a child stops taking an immunosuppressant drug or before they start one.  

Vaccine Safety

One of the largest studies of vaccine safety, published in 2025, reviewed 96 studies of 18 different live attenuated vaccines for immunocompromised patients and pregnant people. It found these vaccines were generally safe for both groups, and immunocompromised children and pregnant people had only slightly more complications than people did.

And a 2020 retrospective study of about 230 children in 10 countries who were taking methotrexate or biologics for a rheumatic disease concluded that live-attenuated MMR and MMVR vaccines were safe, with few serious complications.

However, experts point out that there isn’t much data on the safety of live attenuated vaccines for children using immune-suppressing drugs, so it’s not possible to draw conclusions. Plus, the degree to which children are immunocompromised varies greatly — have they taken high doses of corticosteroids for months or methotrexate for a few weeks? Given this wide variability, it’s impossible to generalize. 

Vaccine Effectiveness

Immunocompromised children and teens treated with biologics don’t have as robust a response to vaccines as healthy children, and antibodies (proteins that recognize and destroy harmful germs) produced by the vaccine lose strength more quickly. But vaccines are effective, though these kids may need booster shots to ensure they’re fully protected. For example, IDSA recommends one extra COVID-19 shot (which does not contain a live virus) for immunocompromised children ages 6 months to 18 years. The AAP recommends two additional shots. 

If your child has arthritis and you have questions about the safety and effectiveness of vaccines, discuss them thoroughly with your child’s doctor. Ultimately, the benefits of live attenuated vaccines — and vaccines in general — are different for each child. You and the doctor should weigh whether the risk of infection is greater than the risk from vaccines.

What Should Parents Do?

There isn’t a single answer for all children when it comes to live vaccines. Kids with JA need vaccinations, but the timing might have to be shifted. The AAP recommends vaccinating children and teens with live virus before they start using a biologic, or delaying live vaccines until they go off it. The AAP considers three months a safe waiting period from stopping most biologics to getting a live vaccine. An exception is rituximab (Rituxan) which should be stopped 6 months to a year before getting a live vaccine. For JAK inhibitors, like tofacitinib (Xeljanz) and baricitinib (Olumiant), the wait time is 30 days.

The Infectious Diseases Society of America (IDSA) bases the safety of live vaccines for immunocompromised people on how much their immunity is suppressed. This varies with different drugs, dosages and disease activity. In general, ISDA also recommends against live vaccines for immunocompromised patients, but it suggests a waiting period of at least four weeks after a live vaccine shot before starting immune-suppressing drugs. 

Talk to your child’s doctor about whether the MMR or MMRV vaccine is safer for your child. It isn’t recommended for kids getting their first MMRV dose between 12 and 72 months of age, when the risk of fever and febrile seizures is higher. But it doesn’t seem to cause problems in older children, and may be a better option because it reduces the number of shots they need.

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.

The final decision about when and whether to get live vaccines should come from informed discussions among parents, kids who are old enough to understand and their health care providers.

Low Vaccination Rates

Children who have juvenile arthritis have lower vaccination rates than healthy kids and even lower rates if they’re immunocompromised, according to several studies. In a 2023 electronic survey, most parents cited active disease, respiratory illness or steroid and biologic drugs as the main reasons for not vaccinating their children. The researchers concluded that pediatric rheumatologists should be more involved in explaining vaccine pros and cons, timelines and possible alternatives for immunocompromised kids.

If your child has arthritis and you have questions about the safety and effectiveness of vaccines, discuss them thoroughly with your child’s doctor. Ultimately, the benefits of live attenuated vaccines — and vaccines in general — are different for each child. You and the doctor should weigh whether the risk of infection is greater than the risk from vaccines.

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. 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.