Vaccinations for Kids on Biologics

Studies find vaccine benefits outweigh risks of infection.

By Linda Rath | Oct. 27, 2021

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 infections.

Types of Vaccines

Most vaccines work by exposing the immune system to a small dose of a virus or bacteria. (Exceptions are the newer mRNA vaccines used to prevent COVID-19.) 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.

A few vaccines, including those for measles, mumps, rubella, chickenpox (varicella), flu (nasal spray only) and rotavirus, contain a weakened form of the live virus (called “live attenuated”) — enough to create immunity but not enough to cause illness in healthy kids. But they’ve generally been advised against for children taking immunosuppressant drugs, like methotrexate or biologics, because of the chance of severe infection from the vaccines themselves. Normally, live attenuated vaccines are postponed until a child stops or before she starts taking immunosuppressant drugs.  

What’s Changed: Vaccine Safety

More recent research suggests that live attenuated vaccines, especially the measles-mumps-rubella (MMR) and MMR-varicella (MMRV) vaccines are safe for children on biologics. The largest study to date, published in Vaccine in 2020, found no vaccine-related infections or disease flares in more than 100 children who received live attenuated vaccine boosters while on immune suppressing medications. Reactions to the vaccine itself were relatively mild: injection site pain, flu-like symptoms and fever.

Talk to your child’s doctor about whether the MMR or MMRV vaccine is safer for your child. Children receiving the first dose of MMRV vaccine between 12 and 72 months of age have a higher risk of fever and febrile seizures, so the Centers for Disease Control and Prevention (CDC) doesn’t recommend it for that age group. The MMRV vaccine doesn’t seem to cause problems in older kids and may be a better option because it cuts down on the number of shots they need.

 The CDC also recommends two non-live pneumonia vaccines — pneumococcal polysaccharide (PPSV23) and pneumococcal 13-valent conjugate (PCV 13) for all kids with arthritis aged 6 to 18. Diseases caused by pneumococcal bacteria can be serious and are especially common in children with weakened immune systems.

Vaccine Effectiveness

Just a few years ago, experts thought vaccines weren’t effective in about half of immunocompromised children. That’s no longer true. Kids treated with biologics might not have as robust a response to vaccines as their healthy peers, and antibodies (proteins that recognize and destroy harmful germs) produced by the vaccine lose strength more quickly. But recent studies show that vaccines still provide immunity against disease, though some children may need booster shots to ensure they’re fully protected.  

Low Vaccination Rates

For reasons that aren’t clear, children with arthritis have lower vaccination rates than healthy kids and even lower if they’re immunocompromised, according to at least one study. It found that 84% of children who had never received immunosuppressant drugs were fully vaccinated compared to 46% of those on biologics. Only 10% of kids with arthritis were vaccinated for flu and 4% for pneumococcal infections. All children, especially those with rheumatic conditions, like arthritis, should get annual flu shots, experts say.

If your child has arthritis and you have questions about the safety and effectiveness of vaccines, discuss them 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.

Live vs. Inactive Vaccines

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, there are only three live vaccines on the childhood immunization schedule — measles, mumps, rubella (MMR), chickenpox (varicella), and nasal spray flu vaccine. It is important to note that the flu shot is inactivated and is safe and recommended for children with arthritis on immune suppressing medications. 

Overall, the review concluded that inactive vaccines are safe and effective 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.

Vaccine Adjustments

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, children may need to wait until the disease is stable enough to go off medications before being vaccinated. Ask your child's doctor about the best times to vaccinate.

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.

Many children are not getting their recommended vaccines given the coronavirus pandemic. However, an American College of Rheumatology taskforce released a guidance statement with a high level of consensus that “Children with pediatric rheumatic disease should continue routine childhood vaccinations (unless contraindicated due to DMARD therapy), including the annual influenza vaccine.”

When Certain Vaccines Are Off-Limits

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 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.

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.

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