EULAR recommends passive immunization for tetanus in children on B-cell depleting drugs
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When a tetanus toxoid vaccination is indicated, pediatric patients treated with B-cell depleting therapy in the past 6 months should receive passive immunization, according to updated EULAR vaccine recommendations.
The recommendation on B-cell therapy is a new addition to the EULAR/PRES recommendations for the vaccination of pediatric patients with autoimmune inflammatory rheumatic diseases, which were first developed in 2011. The updated 2021 guidelines have been published in the Annals of the Rheumatic Diseases.
“Pediatric patients with AIIRD (pedAIIRD) are offered vaccines via National Immunization Programs (NIPs) in order to prevent infections,” Marc H. A. Jansen, MD, PhD, of Wilhelmina Children’s Hospital, in Utrecht, Netherlands, and co-authors wrote. “However, a one-size-fits-all NIP is suboptimal for infection prevention in pedAIIRD patients because additional vaccinations may be required due to specific infection risks, whereas live-attenuated vaccines might be contraindicated in specific circumstances.
“Also, vaccinations may be less effective and timing of vaccination in relation to treatment and disease activity may be warranted,” they added. “Therefore, pedAIIRD patients require a tailor-made vaccination schedule, taking their disease activity, treatment, infection risk, vaccine safety and efficacy into account.”
To construct updated immunization recommendations for pediatric patients with autoimmune and inflammatory rheumatic diseases, EULAR established a steering committee, which first outlined methodology and then formed two additional task forces. The first group was responsible for outlining recommendations for pediatric patients, and the second for recommendations for adult patients. The pediatric task force consisted of 20 experts including rheumatologists, biologists, epidemiologists, immunologists and patient representatives.
The committee conducted a systematic literature review focusing on safety, immunogenicity and efficacy in pediatric patients with autoimmune or inflammatory rheumatic diseases. Additionally, the review investigated the impact of glucocorticoids and disease-modifying antirheumatic drugs in these patients. A 1-day meeting was conducted where the task force for both the pediatric and adult groups jointly discussed evidence gathered in the reviews. Following the first meeting, a second meeting was held toward the end of 2021 for task force members to vote on the recommendations.
In all, the new recommendations include six overarching principles and seven recommendations.
According to the overarching principles, vaccination status, including indications for vaccines in and outside of national programs, should be evaluated every year by a specializing physician. In addition, vaccines should be administered when disease activity is low or in remission when possible. The overarching principles also state that vaccines should ideally be given 2 to 4 weeks before immunosuppressant therapy begins. However, necessary treatment should never be delayed.
Additionally, national immunization programs should be followed for travel vaccinations, except in the case of live-attenuated vaccines. Pediatric patients with autoimmune or inflammatory rheumatic diseases receiving glucocorticosteroids or DMARDs can receive non-live vaccines. Lastly, except for special circumstances, live-attenuated vaccines should not be used in immunosuppressed patients.
The seven updated recommendations state:
- Pediatric patients with autoimmune and inflammatory diseases who are receiving glucocorticosteroids or DMARDs should be considered for receiving non-live seasonal influenza vaccinations.
- All non-vaccinated patients in these groups should receive pneumococcal vaccinations with PCV10 or PCV13.
- Tetanus vaccination should be administered in a way consistent with the general population. In cases where a tetanus toxoid vaccination is indicated, passive immunization is recommended for patients treated with B-cell depleting therapy in the past 6 months.
- Patients with juvenile SLE who have not been vaccinated should be strongly considered for the human papilloma vaccination.
- Patients receiving methotrexate can receive an MMR booster vaccination. The vaccination can be considered in patients receiving low-dose glucocorticosteroids, tumnor necrosis factor inhibitors and anti-interleukin-6 drugs.
- Varicella-naïve patients receiving methotrexate should be strongly considered to receive VZV vaccination. The vaccination can be considered in patients receiving low-dose glucocorticosteroids, TNF inhibitors and anti-interleukin-6 drugs.
- Patients receiving immunosuppression therapy should not be vaccinated for Yellow fever.
No recommendations on COVID-19 vaccines in pediatric patients with autoimmune inflammatory rheumatic diseases were included, as studies were still ongoing by the time of the search, according to the authors.
“Studies from the past decade yielded significant new data on vaccinations in pediatric AIIRD,” Jansen and colleagues wrote. “Specifically, information on the safety of life-attenuated vaccines, the safety and immunogenicity of vaccinations in patients treated with [biological] DMARDs and the experience with the HPV vaccination have been increased and led to the adjustment and upgrade of the recommendations on vaccinations in pedAIIRD.”
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