Updated EULAR recommendations for children with pedAIIRD

People with autoimmune or auto-inflammatory rheumatic diseases have an increased risk of infections. This can be due to the underlying disease itself, or may be caused by treatment with immunomodulating or immunosuppressive drugs. Vaccinations play an important role in infection prevention. But children with pedAIIRD require a vaccination schedule that takes into account their disease activity, current treatment, and infection risk, as well as vaccine efficacy and safety.

EULAR first developed recommendations for the vaccination of children with pedAIIRD in 2011. Since then, the volume of evidence has doubled - and the strength of that evidence has increased. Over the same period, new treatments for pedAIIRD have become available.

The updated EULAR recommendations were developed by a multidisciplinary task force from 9 European countries. The people taking part had expertise in pediatric and adult rheumatology, biology, epidemiology, and immunology. The group also included patient representatives. The work was completed in line with EULAR standardized operating procedures.

The paper developed by EULAR and published in June 2022 issue of the Annals of the Rheumatic Diseases includes six overarching principles and seven recommendations.

The principles say that the vaccination status must be assessed yearly by the treating specialist, and ideally that they be administered during quiescent disease. If possible, vaccinations should be administered 2-4 weeks prior to commencement of immunosuppression - but caution that necessary treatment should never be postponed. In general, vaccinations should follow the national immunization program and guidelines for travel vaccines. Furthermore, this excludes live-attenuated vaccines in immunosuppressed patients, with a notable exception to measles, mumps, and rubella (MMR) booster and varicella vaccination under specific conditions.

The recommendations are simplified from the 2011 version. Previously, recommendations were grouped based on use of immunosuppressive drugs, non-live vaccines, and live-attenuated vaccines - but this created overlap between individual recommendations, In the updated, some recommendations have therefore been combined, and others shifted toward the overarching principles. The resulting recommendations cover vaccination against seasonal 'flu, pneumococcus, tetanus, human papilloma virus, and yellow fever, as well as MMR and varicella.

EULAR hopes these recommendations will support paediatricians, rheumatologists, national immunization agencies, general practitioners, patients, and national societies in achieving safe and effective vaccination and optimal infection prevention in immunocompromised children with AIIRDs.