Juvenile Idiopathic Arthritis (JIA) broadly refers to a group of heterogenous diseases that share the common feature of chronic inflammatory arthritis of unknown cause lasting longer than 6 weeks with onset before age 16 years of age [3]. Patients with autoimmune diseases such as JIA remain under-vaccinated due to hypothetical concern for infection development. However, it is crucial for these patients to be protected against vaccine-preventable illnesses due to their underlying immune dysfunction as well as the various immunomodulatory drugs that are used in its treatment.
In the United States, the magnitude and number of measles outbreaks has increased, which has provoked a variety of policy changes aimed at improving vaccine coverage [5]. Phadke et al. reported that unvaccinated individuals continue to constitute a majority of cases in measles outbreaks. Additionally, they noted that in the context of the COVID-19 pandemic, immunization monitoring systems have identified marked reductions in the number of doses of measles-containing vaccine that have been ordered and administered. They highlighted the importance of having more data sources that can be used to make decisions about vaccine policy.
Regarding existing studies on vaccinations in children with rheumatic diseases, Toplak et al concluded that booster dose of live-attenuated vaccines in children treated with biologics was safe, but not always providing a protective immune response. In the last update on vaccinations in children with rheumatic diseases published in 2015, 15 studies including 296 patients treated with biologics were found [6]. A majority of these studied the use of non-live vaccines in children treated with biologics, and 4 studies investigated booster doses of live-attenuated vaccines among children treated with biologics. None of the patients in these studies had severe adverse events or autoimmune disease relapse after the vaccination. Prior to 2015, 4 studies of live-attenuated vaccination in children treated with biologic therapy were published; two of these studies investigated MMR vaccination in JIA patients, including 14 patients also receiving biologic therapy. Ten patients were treated with etanercept at the time of booster MMR, one with adalimumab and three with anti-IL1 therapy [2, 4]. There were no serious adverse events from vaccination.
Recently, live vaccine recommendations in Europe were updated at the 2017 European League Against Rheumatism-Pediatric Rheumatology European Society (EULAR-PReS) Task Force for Vaccination. PReS recommendation for live vaccines for pediatric patients was updated based on small case series and on expert opinion. Currently, they recommend that “vaccination with live-attenuated vaccines in patients on high-dose disease modifying anti-rheumatic drugs (DMARDs), high dose glucocorticosteroids (GCS) or biologic agents can be considered on a case-by-case basis, weighing the risk of infections against the hypothetical risk of inducing infection through vaccination [1,7].” Current Center for Disease Control (CDC) childhood vaccines guidelines recommend initiation of live vaccines (MMR and VZV) at one year, with a booster dose given between 4 and 6 years of age for immunocompetent children [8]. Per these guidelines, live vaccines are typically considered contraindicated in immunocompromised patients.
Considering that vaccine hesitancy and refusal by parents to vaccinate their children is on the rise and the concomitant increase in measles outbreaks, it is important for physicians to properly counsel parents to facilitate protection against these vaccine-preventable illnesses in this susceptible population.
Specifically, our aim was:
To provide retrospective evidence that MMR/Varicella live vaccines do not cause infections from exposure to the vaccine in patients with JIA being treated with biologics with or without methotrexate.
Criteria for Subject Selection:
Gender of subjects: equitable inclusion of males and females.
Age of subjects: Age 1-2 or 5-6 while being treated with a biologic, which are ages when children are usually vaccinated for MMR and Varicella.
Racial and Ethnic Origin: there will be no restriction on inclusion based on race or ethnic origin
Inclusion criteria: Juvenile idiopathic arthritis patients treated with adalimumab, canakinumab, etanercept, infliximab, tocilizumab, or abatacept, with or without methotrexate who received a live vaccine (MMR or VZV) while actively being treated.
Exclusion criteria: Any patient concurrently being treated with steroids or with active disease at time of vaccination.