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Jansen MHA, Rondaan C, Legger GE, Minden K, Uziel Y, Toplak N, Maritsi D, van den Berg L, Berbers GAM, Bruijning P, Egert Y, Normand C, Bijl M, Foster HE, Koné-Paut I, Wouters C, Ravelli A, Elkayam O, Wulffraat NM, Heijstek MW. EULAR/PRES recommendations for vaccination of paediatric patients with autoimmune inflammatory rheumatic diseases: update 2021. Ann Rheum Dis 2023; 82:35-47. [PMID: 35725297 DOI: 10.1136/annrheumdis-2022-222574] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/24/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Recent insights supporting the safety of live-attenuated vaccines and novel studies on the immunogenicity of vaccinations in the era of biological disease-modifying antirheumatic drugs in paediatric patients with autoimmune/inflammatory rheumatic diseases (pedAIIRD) necessitated updating the EULAR recommendations. METHODS Recommendations were developed using the EULAR standard operating procedures. Two international expert committees were formed to update the vaccination recommendations for both paediatric and adult patients with AIIRD. After a systematic literature review, separate recommendations were formulated for paediatric and adult patients. For pedAIIRD, six overarching principles and seven recommendations were formulated and provided with the level of evidence, strength of recommendation and Task Force level of agreement. RESULTS In general, the National Immunisation Programmes (NIP) should be followed and assessed yearly by the treating specialist. If possible, vaccinations should be administered prior to immunosuppressive drugs, but necessary treatment should never be postponed. Non-live vaccines can be safely given to immunosuppressed pedAIIRD patients. Mainly, seroprotection is preserved in patients receiving vaccinations on immunosuppression, except for high-dose glucocorticoids and B-cell depleting therapies. Live-attenuated vaccines should be avoided in immunosuppressed patients. However, it is safe to administer the measles-mumps-rubella booster and varicella zoster virus vaccine to immunosuppressed patients under specific conditions. In addition to the NIP, the non-live seasonal influenza vaccination should be strongly considered for immunosuppressed pedAIIRD patients. CONCLUSIONS These recommendations are intended for paediatricians, paediatric rheumatologists, national immunisation agencies, general practitioners, patients and national rheumatology societies to attain safe and effective vaccination and optimal infection prevention in immunocompromised pedAIIRD patients.
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Affiliation(s)
- Marc H A Jansen
- Department of Paediatric Immunology & Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands .,RITA, European Reference Networks, Brussels, Belgium
| | - Christien Rondaan
- Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, Groningen, The Netherlands
| | - Geertje E Legger
- RITA, European Reference Networks, Brussels, Belgium.,Department of Paediatric Rheumatology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Kirsten Minden
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin, Berlin, Germany.,Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Yosef Uziel
- Paediatric Rheumatology Unit, Department of Paediatrics, Meir Medical Center, Kfar Saba, Israel
| | - Natasa Toplak
- RITA, European Reference Networks, Brussels, Belgium.,Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, Ljubljana, Slovenia
| | - Despoina Maritsi
- Infectious Diseases, Immunology and Rheumatology Unit, Department of Paediatrics, Kyriakou Children's Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Lotte van den Berg
- Dutch JIA Patient and Parent Organisation (JVN), Member of ENCA, Amsterdam, The Netherlands
| | - Guy A M Berbers
- Centre for Infectious Disease Control Netherlands, Laboratory for Infectious Diseases and Screening, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Patricia Bruijning
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yona Egert
- European Network Childhood Arthritis (ENCA) Patient Organisation, Judea and Samaria Area, Israel
| | - Christophe Normand
- MCI Secretariat, European Network for Children with Arthritis (ENCA), Geneva, Switzerland
| | - Marc Bijl
- Department of Internal Medicine and Rheumatology, Martini Hospital Groningen, Groningen, The Netherlands
| | - Helen E Foster
- Population and Health Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Isabelle Koné-Paut
- Department of Paediatric Rheumatology and CEREMAIA, Hôpital Bicêtre, AP HP, Université Paris Saclay, Paris, France
| | - Carine Wouters
- Division of Paediatric Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Angelo Ravelli
- RITA, European Reference Networks, Brussels, Belgium.,Department of Rheumatology, Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy.,Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Ori Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center and the Sackler faculty of medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nicolaas M Wulffraat
- Department of Paediatric Immunology & Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,RITA, European Reference Networks, Brussels, Belgium
| | - Marloes W Heijstek
- RITA, European Reference Networks, Brussels, Belgium.,Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
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Jansen MH, Rondaan C, Legger G, Minden K, Uziel Y, Toplak N, Maritsi D, van den Berg M, Berbers G, Bruijning P, Egert Y, Normand C, Bijl M, Foster H, Kone-Paut I, Wouters C, Ravelli A, Elkayam O, Wulffraat NM, Heijstek MW. Efficacy, Immunogenicity and Safety of Vaccination in Pediatric Patients With Autoimmune Inflammatory Rheumatic Diseases (pedAIIRD): A Systematic Literature Review for the 2021 Update of the EULAR/PRES Recommendations. Front Pediatr 2022; 10:910026. [PMID: 35874582 PMCID: PMC9298835 DOI: 10.3389/fped.2022.910026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background In 2011, the first European League Against Rheumatism (EULAR) vaccination recommendations for pediatric patients with autoimmune inflammatory rheumatic diseases (pedAIIRD) were published. The past decade numerous new studies were performed to assess the safety, efficacy and immunogenicity of vaccinations in pedAIIRD. A systematic literature review (SLR) was therefore performed to serve as the basis for the updated 2021 EULAR/PRES recommendations. Methods An SLR was performed according to the standard operating procedures for EULAR-endorsed recommendations. Primary outcomes were efficacy, immunogenicity and safety of vaccination in pedAIIRD. The search was performed in Medline, Embase and the Cochrane Library and included studies published from November 2010 until July 2020. Results The SLR yielded 57 studies which were included for critical appraisal and data extraction. Only 8 studies described the occurrence of vaccine-preventable infections after vaccination (efficacy), none of these studies were powered to assess efficacy. The majority of studies assessed (humoral) immune responses as surrogate endpoint for vaccine efficacy. Studies on non-live vaccines showed that these were safe and in general immunogenic. Biologic disease-modifying antirheumatic drugs (bDMARDs) in general did not significantly reduce seroprotection rates, except for B-cell depleting therapies which severely hampered humoral responses. Four new studies on human papilloma virus vaccination showed that this vaccine was safe and immunogenic in pedAIIRD. Regarding live-attenuated vaccinations, level 1 evidence of the measles mumps rubella (MMR) booster vaccination became available which showed the safety of this booster for patients treated with methotrexate. In addition, level 3 evidence became available that suggested that the MMR and varicella zoster virus (VZV) vaccination for patients on low dose glucocorticosteroids and bDMARDs might be safe as well. Conclusions The past decade, knowledge on the safety and immunogenicity of (live-attenuated) vaccines in pedAIIRD significantly increased. Data on efficacy (infection prevention) remains scarce. The results from this SLR are the basis for the updated EULAR/PRES vaccination recommendations in pedAIIRD.
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Affiliation(s)
- Marc H. Jansen
- Department of Paediatric Immunology & Rheumatology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
- RITA, European Reference Networks, Brussels, Belgium
| | - Christien Rondaan
- Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Geertje Legger
- RITA, European Reference Networks, Brussels, Belgium
- Department of Paediatric Rheumatology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Kirsten Minden
- Department of Paediatric Respiratory Medicine, Immunology and Critical Care Medicine, Deutsches Rheuma-Forschungszentrum Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Berlin, Germany
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Yosef Uziel
- Paediatric Rheumatology Unit, Department of Paediatrics, Meir Medical Centre, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nataša Toplak
- RITA, European Reference Networks, Brussels, Belgium
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Despoina Maritsi
- Infectious Diseases, Immunology and Rheumatology Unit, Second Department of Paediatrics, Medical School, P. & A. Kyriakou Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Guy Berbers
- Centre for Infectious Disease Control, Laboratory for Infectious Diseases and Screening, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
| | - Patricia Bruijning
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Yona Egert
- European Network for Children With Arthritis (ENCA), MCI Secretariat, Geneva, Switzerland
| | - Christophe Normand
- RITA, European Reference Networks, Brussels, Belgium
- European Network for Children With Arthritis (ENCA), MCI Secretariat, Geneva, Switzerland
| | - Marc Bijl
- Department of Rheumatology and Clinical Immunology, Martini Hospital Groningen, Groningen, Netherlands
| | - Helen Foster
- Population and Health Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Isabelle Kone-Paut
- RITA, European Reference Networks, Brussels, Belgium
- Department of Paediatric Rheumatology and CEREMAIA, Bicêtre University Hospital, Université Paris Saclay, Paris, France
| | - Carine Wouters
- Division of Paediatric Rheumatology University Hospitals Leuven, Leuven, Belgium
| | - Angelo Ravelli
- RITA, European Reference Networks, Brussels, Belgium
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Ori Elkayam
- Department of Rheumatology, Sackler Faculty of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Nicolaas M. Wulffraat
- Department of Paediatric Immunology & Rheumatology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
- RITA, European Reference Networks, Brussels, Belgium
| | - Marloes W. Heijstek
- RITA, European Reference Networks, Brussels, Belgium
- Department of Rheumatology & Clinical Immunology, University Medical Centre Utrecht, Utrecht, Netherlands
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Bizjak M, Heshin-Bekenstein M, Jansen MHA, Ziv A, Angevare S, Uziel Y, Wulffraat NM, Toplak N. Vaccinology in pediatric rheumatology: Past, present and future. Front Pediatr 2022; 10:1098332. [PMID: 36704144 PMCID: PMC9872015 DOI: 10.3389/fped.2022.1098332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/22/2022] [Indexed: 01/11/2023] Open
Abstract
With the introduction of biological disease-modifying antirheumatic drugs (bDMARDs), the treatment of pediatric patients with autoimmune/inflammatory rheumatic diseases (pedAIIRD) has advanced from the "Stone Age" to modern times, resulting in much better clinical outcomes. However, everything comes with a price, and use of new bDMARDs has resulted in an increased risk of infections. Therefore, preventing infections in pedAIIRD patients is one of the top priorities. The most effective preventive measure against infection is vaccination. The first study on humoral immunity after vaccination in pediatric rheumatology was published in 1974 and on safety in 1993. For many years, data about safety and immunogenicity in pedAIIRD patients were available only for non-live vaccines and the first studies on live-attenuated vaccines in pedAIIRD patients treated with immunosuppressive therapy were available only after 2007. Even today the data are limited, especially for children treated with bDMARDs. Vaccinations with non-live vaccines are nowadays recommended, although their long-term immunogenicity and efficacy in pedAIIRD patients are still under investigation. Vaccinations with live-attenuated vaccines are not universally recommended in immunosuppressed patients. However, measles-mumps-rubella booster and varicella zoster virus vaccination can be considered under specific conditions. Additional research is needed to provide more evidence on safety and immunogenicity, especially regarding live-attenuated vaccines in immunosuppressed patients with pedAIIRD. Due to the limited number of these patients, well-designed, prospective, international studies are needed. Further challenges were presented by the COVID-19 pandemic. This mini review article reviews past and present data and discusses the future of vaccinology in pediatric rheumatology.
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Affiliation(s)
- Masa Bizjak
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Merav Heshin-Bekenstein
- Pediatric Rheumatology Service, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marc H A Jansen
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Amit Ziv
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, Kfar Saba, Israel
| | - Saskya Angevare
- European Network for Children with Arthritis, Geneva, Switzerland.,KAISZ, Amsterdam, Netherlands
| | - Yosef Uziel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, Kfar Saba, Israel
| | - Nicolaas M Wulffraat
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, Netherlands
| | - Natasa Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Keller M, Pittet LF, Zimmermann P. Immunogenicity and safety of routine vaccines in children and adolescents with rheumatic diseases on immunosuppressive treatment - a systematic review. Eur J Pediatr 2022; 181:1329-1362. [PMID: 34936010 PMCID: PMC8692821 DOI: 10.1007/s00431-021-04283-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 09/25/2021] [Accepted: 10/03/2021] [Indexed: 02/02/2023]
Abstract
UNLABELLED The immunogenicity of vaccines in children with juvenile autoimmune rheumatic diseases (JARDs) can be reduced, there are additional safety concerns around vaccination, and there is a potential for worsening in disease activity. In this systematic review, we summarise studies that investigated the immunogenicity and safety of routine vaccines in children and adolescents with JARD on immunosuppressive treatment. We identified 37 studies investigating 2571 children and adolescents with JARD on immunosuppressive treatment and 4895 control children. Of the 56 geometric mean antibody titres measured, 19 (34%) were lower, six (11%) higher, and 31 (55%) similar; of the 39 seroprotection rates measured, 10 (26%) were lower, two (5%) higher, and 27 (69%) similar; and of the 27 seroconversion rates measured, nine (33%) were lower, two (8%) higher, and 16 (59%) similar in children with JARD on immunosuppressive treatment compared with control children. However, many of the studies were underpowered, and not designed to show non-inferiority between children with JARD and controls. Subgroup analysis for different types of immunosuppressive treatments was not feasible, as most studies did not report results by treatment. Severe adverse events were reported in 38 children (33 with juvenile idiopathic arthritis, four with systemic lupus erythematosus, and one in a healthy child); most of them were likely not related to the vaccination (e.g. elective hospitalisation or surgery). A worsening in disease activity was reported in 44 (2%) children with JARD; again, many of them were likely not related to the vaccination. There were no safety concerns with live attenuated vaccines; however, only few studies reported results for this. CONCLUSION Vaccination in children with JARD on immunosuppressive treatment is safe and should be promoted, especially since these children are at increased risk for infection. The importance for the completion of vaccination schedules should be stressed. Strategies to compensate for the lower vaccine responses, which are found in approximately one-third of these children, include measuring antibody levels to determine the optimal timing for the administration of additional booster doses. WHAT IS KNOWN • Children with juvenile autoimmune rheumatic diseases (JARDs) are at higher risk for infections, due to their underlying disease and their immunosuppressive treatment. • In children with JARD, the immunogenicity of vaccines might be reduced, and concerns about safety or the potential for worsening in disease activity after vaccination exist. WHAT IS NEW • Our systematic review shows that vaccines in children with JARDs on immunosuppressive treatment are safe and immunogenic. • There are several limitations of the currently published studies, including random timing of measuring vaccine responses and age differences between children with JARD and control groups. Many of the studies were underpowered, and not designed to show non-inferiority between children with JARD and controls.
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Affiliation(s)
- Michèle Keller
- Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Laure F. Pittet
- Pediatric Infectious Diseases Unit, Division of General Pediatrics, Department of Pediatrics, Gynecology & Obstetrics, Faculty of Medicine, University Hospitals of Geneva and University of Geneva’s, Geneva, Switzerland ,Infectious Diseases Group, Murdoch Children’s Research Institute, Parkville, VIC Australia ,Department of Paediatrics, The University of Melbourne, Parkville, VIC Australia
| | - Petra Zimmermann
- Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland. .,Infectious Diseases Group, Murdoch Children's Research Institute, Parkville, VIC, Australia. .,Department of Paediatrics, Fribourg Hospital HFR, Fribourg, Switzerland.
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Current Take on Systemic Sclerosis Patients' Vaccination Recommendations. Vaccines (Basel) 2021; 9:vaccines9121426. [PMID: 34960174 PMCID: PMC8708328 DOI: 10.3390/vaccines9121426] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare autoimmune inflammatory rheumatic disease. The prevalence of SSc ranges from 7 to 700 cases per million worldwide. Due to multiple organ involvement and constant inflammatory state, this group of patients presents an increased risk of infectious diseases. This paper aimed to gather the up-to-date evidence on vaccination strategies for patients with SSc and to be a useful tool for the prevention and management of infectious diseases. The authors conducted a scoping review in which each paragraph presents data on a specific vaccine’s safety, immunogenicity, and efficacy. The work deals with the following topics: SARS-CoV-2, seasonal influenza, S. pneumoniae, HAV, HBV, HZV, N. meningitidis, H. influenzae, HPV, and diphtheria-tetanus-pertussis.
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Hügle B, Krumrey-Langkammerer M, Haas JP. Infection with SARS-CoV-2 causes flares in patients with juvenile idiopathic arthritis in remission or inactive disease on medication. Pediatr Rheumatol Online J 2021; 19:163. [PMID: 34844609 PMCID: PMC8628278 DOI: 10.1186/s12969-021-00653-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/16/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Flares of juvenile idiopathic arthritis (JIA) have been described in the context of various infections. Flares of rheumatic diseases in adults have been described following infection with SARS-CoV-2 in several cohorts. So far, the effect of infection with SARS-CoV-2 on the course of JIA is unknown. METHODS The database of the German Center for Pediatric and Adolescent Rheumatology was searched for patients with confirmed infection with SARS-CoV-2 and subsequent disease flare, admitted from July 2020 until June 2021. cJADAS-27, ESR and C-reactive protein, as well as uveitis activity, medication at the time of flare and treatment of flare was extracted. Patient cases were described individually. RESULTS Out of 988 patients admitted, five patients with remission off medication (n = 2) or inactive disease on medication (n = 3) were identified, with flare symptoms up to four weeks after infection with SARS-CoV-2. CONCLUSIONS Flares can occur after infection with SARS-CoV-2 in patients with JIA in remission or inactive disease on medication. Treating physicians need to be aware of this fact, especially when counseling patients with rheumatic diseases about the respective dangers of COVID-19 and vaccination against SARS-CoV-2.
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Affiliation(s)
- Boris Hügle
- German Center for Pediatric and Adolescent Rheumatology, Gehfeldstrasse 24, 82467, Garmisch-Partenkirchen, Germany.
| | - Manuela Krumrey-Langkammerer
- grid.500039.fGerman Center for Pediatric and Adolescent Rheumatology, Gehfeldstrasse 24, 82467 Garmisch-Partenkirchen, Germany
| | - Johannes-Peter Haas
- grid.500039.fGerman Center for Pediatric and Adolescent Rheumatology, Gehfeldstrasse 24, 82467 Garmisch-Partenkirchen, Germany
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Nicastro E, Verdoni L, Bettini LR, Zuin G, Balduzzi A, Montini G, Biondi A, D'Antiga L. COVID-19 in Immunosuppressed Children. Front Pediatr 2021; 9:629240. [PMID: 33996683 PMCID: PMC8116542 DOI: 10.3389/fped.2021.629240] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/03/2021] [Indexed: 12/15/2022] Open
Abstract
Following the spread of the SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19) to a global pandemic, concerns have arisen for the disease impact in at-risk populations, especially in immunocompromised hosts. On the other hand, clinical studies have clarified that the COVID-19 clinical burden is mostly due to over-inflammation and immune-mediated multiorgan injury. This has led to downsizing the role of immunosuppression as a determinant of outcome, and early reports confirm the hypothesis that patients undergoing immunosuppressive treatments do not have an increased risk of severe COVID-19 with respect to the general population. Intriguingly, SARS-CoV-2 natural reservoirs, such as bats and mice, have evolved mechanisms of tolerance involving selection of genes optimizing viral clearance through interferon type I and III responses and also dampening inflammasome response and cytokine expression. Children exhibit resistance to COVID-19 severe manifestations, and age-related features in innate and adaptive response possibly explaining this difference are discussed. A competent recognition by the innate immune system and controlled pro-inflammatory signaling seem to be the pillars of an effective response and the premise for pathogen clearance in SARS-CoV-2 infection. Immunosuppression-if not associated with other elements of fragility-do not represent per se an obstacle to this competent/tolerant phenotype in children. Several reports confirm that children receiving immunosuppressive medications have similar clinical involvement and outcomes as the pediatric general population, indicating that maintenance treatments should not be interrupted in suspect or confirmed SARS-CoV-2 infection.
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Affiliation(s)
- Emanuele Nicastro
- Pediatric Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lucio Verdoni
- Pediatric Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Laura Rachele Bettini
- MBBM Foundation, Pediatric Department, Hospital San Gerardo, University of Milano Bicocca, Monza, Italy
| | - Giovanna Zuin
- MBBM Foundation, Pediatric Department, Hospital San Gerardo, University of Milano Bicocca, Monza, Italy
| | - Adriana Balduzzi
- MBBM Foundation, Pediatric Department, Hospital San Gerardo, University of Milano Bicocca, Monza, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda, Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Andrea Biondi
- MBBM Foundation, Pediatric Department, Hospital San Gerardo, University of Milano Bicocca, Monza, Italy
| | - Lorenzo D'Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
- Pediatric Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
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Vaccinations Do Not Increase Arthritis Flares in Juvenile Idiopathic Arthritis: A Study of the Relationship between Routine Childhood Vaccinations on the Australian Immunisation Schedule and Arthritis Activity in Children with Juvenile Idiopathic Arthritis. Int J Rheumatol 2020; 2020:1078914. [PMID: 32831849 PMCID: PMC7424527 DOI: 10.1155/2020/1078914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 06/30/2020] [Indexed: 12/26/2022] Open
Abstract
Background Juvenile idiopathic arthritis (JIA) is a collective term for a group of inflammatory conditions of uncertain origin, which causes chronic arthritis in one or more joints. The clinical course of JIA is characterised by episodes of increased activity, termed flares. Vaccinations have previously been proposed as a “trigger” for some flares, although evidence supporting this is scant. Objective To explore whether routine childhood vaccinations are associated with an increased risk of flares of arthritis activity in children with JIA. Methods Patients aged below 6 years with a diagnosis of JIA were recruited from the Rheumatology Clinical Database at the Royal Children's Hospital, Melbourne, Australia, from 1 January 2010 to 30 April 2016. Patient immunisation status was cross-checked with the Australian Childhood Immunisation Register (ACIR). The self-controlled case series methodology (Rowhani-Rahbar et al., 2012) was applied to determine whether the risk of arthritis flares in the three months following immunisation was greater than the baseline risk for each patient. Results 138 patients were included in the study. 32 arthritis flares occurred in the 90 days following immunisation. The risk of arthritis flares during the 90 days following immunisation was reduced compared with patients' baseline risk (RR 0.59 (95% CI 0.39-0.89, p = 0.012)). Conclusion Routine childhood immunisations were not associated with arthritis flare onset in patients with JIA. The risk of arthritis flares in the 90 days following vaccination was lower than the baseline risk. In the context of COVID19, vaccination will not increase interaction with the healthcare system beyond the immunisation encounter.
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9
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Licciardi F, Giani T, Baldini L, Favalli EG, Caporali R, Cimaz R. COVID-19 and what pediatric rheumatologists should know: a review from a highly affected country. Pediatr Rheumatol Online J 2020; 18:35. [PMID: 32321540 PMCID: PMC7175817 DOI: 10.1186/s12969-020-00422-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/03/2020] [Indexed: 01/08/2023] Open
Abstract
On March 11th, 2020 the World Health Organization declared COVID-19 a global pandemic. The infection, transmitted by 2019 novel coronavirus (2019-nCov), was first discovered in December 2019, in Wuhan, Hubei Province, and then rapidly spread worldwide. Italy was early and severely involved, with a critical spread of the infection and a very high number of victims. Person-to-person spread mainly occurs via respiratory droplets and contact. The median incubation period is 5 days. The spectrum of respiratory symptoms may range from mild to severe, strictly depending on the age of the patient and the underlying comorbidities.In children COVID-19 related disease is less frequent and less aggressive. In Italy 1% of positive cases are under 18 years of age, and no deaths have been recorded before 29 years of age. For patients affected by rheumatic disease, despite the concerns related to the imbalance of their immune response and the effect of immunosuppressive treatments, there are still few data to understand the real consequences of this infection. Major scientific societies have issued recommendations to help rheumatologists in caring their patients. Interestingly, some of the drugs mostly used by rheumatologists appear to be promising in critical COVID-19 infected patients, where the hyperinflammation and cytokine storm seem to drive to the multiorgan failure.Pediatric rheumatologists are expected to play a supporting role in this new front of COVID-19 pandemic, both as general pediatricians treating infected children, and as rheumatologists taking care of their rheumatic patients, as well as offering their experience in the possible alternative use of immunomodulatory drugs.
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Affiliation(s)
- Francesco Licciardi
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Teresa Giani
- AOU Meyer, V.le Pieraccini 24, 50139, Florence, Italy.
- Department of Medical Biotechnology, University of Siena, Siena, Italy.
| | - Letizia Baldini
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Ennio Giulio Favalli
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
| | - Roberto Caporali
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
| | - Rolando Cimaz
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
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Furer V, Rondaan C, Heijstek MW, Agmon-Levin N, van Assen S, Bijl M, Breedveld FC, D'Amelio R, Dougados M, Kapetanovic MC, van Laar JM, de Thurah A, Landewé RBM, Molto A, Müller-Ladner U, Schreiber K, Smolar L, Walker J, Warnatz K, Wulffraat NM, Elkayam O. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2019; 79:39-52. [DOI: 10.1136/annrheumdis-2019-215882] [Citation(s) in RCA: 357] [Impact Index Per Article: 71.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 12/16/2022]
Abstract
To update the European League Against Rheumatism (EULAR) recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD) published in 2011. Four systematic literature reviews were performed regarding the incidence/prevalence of vaccine-preventable infections among patients with AIIRD; efficacy, immunogenicity and safety of vaccines; effect of anti-rheumatic drugs on the response to vaccines; effect of vaccination of household of AIIRDs patients. Subsequently, recommendations were formulated based on the evidence and expert opinion. The updated recommendations comprise six overarching principles and nine recommendations. The former address the need for an annual vaccination status assessment, shared decision-making and timing of vaccination, favouring vaccination during quiescent disease, preferably prior to the initiation of immunosuppression. Non-live vaccines can be safely provided to AIIRD patients regardless of underlying therapy, whereas live-attenuated vaccines may be considered with caution. Influenza and pneumococcal vaccination should be strongly considered for the majority of patients with AIIRD. Tetanus toxoid and human papilloma virus vaccination should be provided to AIIRD patients as recommended for the general population. Hepatitis A, hepatitis B and herpes zoster vaccination should be administered to AIIRD patients at risk. Immunocompetent household members of patients with AIIRD should receive vaccines according to national guidelines, except for the oral poliomyelitis vaccine. Live-attenuated vaccines should be avoided during the first 6 months of life in newborns of mothers treated with biologics during the second half of pregnancy. These 2019 EULAR recommendations provide an up-to-date guidance on the management of vaccinations in patients with AIIRD.
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11
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Marino A, Giani T, Cimaz R. Risks associated with use of TNF inhibitors in children with rheumatic diseases. Expert Rev Clin Immunol 2018; 15:189-198. [PMID: 30451548 DOI: 10.1080/1744666x.2019.1550359] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Tumor necrosis factor alpha (TNF-α) is a pro-inflammatory cytokine involved in the pathogenesis of many inflammatory diseases. Several drugs blocking TNF-α are employed in clinical practice in pediatrics. Given their action on the immune system, TNF-α inhibitors have raised concerns on their safety profile since their introduction. A broad spectrum of side effects related to TNF inhibition has been reported: immunogenicity, infectious diseases, malignancies, and others. Areas covered: In order to assess the risk related to the use of anti-TNF-α agents in children with rheumatic diseases we analyzed data obtained from retrospective and prospective safety studies, case reports and case series, and controlled trials. Expert commentary: Anti-TNF-α agents have shown a remarkably good safety profile in the pediatric population so far. However, there are lots of questions to be answered and maintaining active surveillance on these drugs is necessary in order to not overlook any possible unexpected adverse effects.
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Affiliation(s)
- Achille Marino
- a Department of Pediatrics, Desio Hospital , ASST Monza , Desio (MB) , Italy.,b PhD student in Biomedical Sciences , University of Florence , Florence , Italy
| | - Teresa Giani
- c Department of Medical Biotechnology , University of Siena , Siena , Italy.,d Rheumatology Unit, Meyer Children's Hospital , University of Florence , Florence , Italy
| | - Rolando Cimaz
- e Department of Neurosciences, Psychology, Drug Research and Child Health, Rheumatology Unit, Meyer Children's Hospital , University of Florence , Florence , Italy
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12
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Camacho-Lovillo MS, Bulnes-Ramos A, Goycochea-Valdivia W, Fernández-Silveira L, Núñez-Cuadros E, Neth O, Pérez-Romero P. Immunogenicity and safety of influenza vaccination in patients with juvenile idiopathic arthritis on biological therapy using the microneutralization assay. Pediatr Rheumatol Online J 2017; 15:62. [PMID: 28784185 PMCID: PMC5547451 DOI: 10.1186/s12969-017-0190-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 08/01/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Seasonal influenza virus vaccination should be considered in all pediatric patients with rheumatic diseases. Few studies have addressed influenza vaccination safety and efficacy in this group. We aim to prospectively evaluate immunogenicity and safety of the trivalent inactivated influenza vaccine including A/H1N1, A/H3N2 and B strains in children with juvenile idiopathic arthritis (JIA) receiving biological therapy. METHODS Thirty-five children diagnosed with JIA and 6 healthy siblings were included. Serum samples were collected prior to, 4-8 weeks and one year after vaccination. Microneutralization assays were used to determine neutralizing antibody titers. The type and duration of therapy were analyzed to determine its effect on vaccine response. Clinical data of the participants were collected throughout the study including severe adverse events (SAE) and adverse events following immunization (AEFI). RESULTS Twenty-five patients (74.3%) received biological treatment for JIA; anti TNF-α was prescribed in 15, anti IL-1 receptor in 4 and anti IL-6 receptor therapy in 6 children. The seroprotection rate 4-8 weeks after vaccination in the JIA group was 96% for influenza A/(H1N1)pdm and influenza A/H3N2, and 88% for influenza B. No differences were found in GMT, seroprotection and seroconversion rates for the three influenza strains between the control group and patients receiving biological therapy. Furthermore, long-term seroprotection at 12 months after vaccination was similar in patients receiving either biological or non-biological treatments. No SAEs were observed. CONCLUSIONS In this study, influenza vaccination was safe and immunogenic in children with JIA receiving biological therapy.
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Affiliation(s)
- M. S. Camacho-Lovillo
- Unidad de Enfermedades Infecciosas e Inmunopatologías Pediátrica, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - A. Bulnes-Ramos
- 0000 0000 9542 1158grid.411109.cInstituto de Biomedicina de Sevilla (IBIS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Sevilla, Spain
| | - W. Goycochea-Valdivia
- Unidad de Enfermedades Infecciosas e Inmunopatologías Pediátrica, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - L. Fernández-Silveira
- Unidad de Enfermedades Infecciosas e Inmunopatologías Pediátrica, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - E. Núñez-Cuadros
- grid.411457.2Unidad de Reumatología Pediátrica, Hospital Materno Infantil, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - O. Neth
- Unidad de Enfermedades Infecciosas e Inmunopatologías Pediátrica, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - P. Pérez-Romero
- 0000 0000 9542 1158grid.411109.cInstituto de Biomedicina de Sevilla (IBIS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Sevilla, Spain
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13
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Abstract
In 2011, the European League Against Rheumatism (EULAR) published recommendations regarding the vaccination of children with rheumatic diseases. These recommendations were based on a systematic literature review published in that same year. Since then, the evidence body on this topic has grown substantially. This review provides an update of the systematic literature study of 2011, summarizing all the available evidence on the safety and immunogenicity of vaccination in paediatric patients with rheumatic diseases. The current search yielded 21 articles, in addition to the 27 articles described in the 2011 review. In general, vaccines are immunogenic and safe in this patient population. The effect of immunosuppressive drugs on the immunogenicity of vaccines was not detrimental for glucocorticosteroids and methotrexate. Biologicals could accelerate a waning of antibody levels over time, although most patients were initially protected adequately. Overall, persistence of immunological memory may be reduced in children with rheumatic diseases, which shows the need for (booster) vaccination. This update of the 2011 systematic literature review strengthens the evidence base for the EULAR recommendations, and it must be concluded that vaccinations in patients with rheumatic diseases should be advocated.
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Abstract
Infection with influenza A virus is responsible for considerable morbidity and mortality in children worldwide. While it is apparent that adequate activation of the innate immune system is essential for pathogen clearance and host survival, an excessive inflammatory response to infection is detrimental to the young host. A review of the literature indicates that innate immune responses change throughout childhood. Whether these changes are genetically programmed or triggered by environmental cues is unknown. The objectives of this review are to summarize the role of innate immunity in influenza A virus infection in the young child and to highlight possible differences between children and adults that may make children more susceptible to severe influenza A infection. A better understanding of age-related differences in innate immune signaling will be essential to improve care for this high-risk population.
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Affiliation(s)
- Bria M. Coates
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois2Division of Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Kelly L. Staricha
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kristin M. Wiese
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Karen M. Ridge
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois4Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
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15
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Minden K, Speth F, Huppertz HI, Borte M. [Immunization in children and adolescents with rheumatic and musculoskeletal diseases]. Z Rheumatol 2015; 73:878-89. [PMID: 25479932 DOI: 10.1007/s00393-014-1396-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children and adolescents with inflammatory rheumatic diseases have a disease and treatment-related increased risk of infections. This risk includes vaccine-preventable diseases; therefore, vaccinations represent an important preventive measure against infection in these patients. However, approximately one in three patients with a juvenile rheumatic disease is nowadays still inadequately vaccinated, mostly due to uncertainty regarding the efficacy and safety of vaccination in these patients. OBJECTIVES This paper summarizes the available evidence regarding the efficacy and safety of vaccinations in children and adolescents with rheumatic diseases and gives recommendations for the clinical practice. RESULTS AND PERSPECTIVES Almost 2000 children and adolescents with rheumatic diseases were examined in the more than 30 previously published vaccination studies, comprising nearly all standard vaccinations in the immunization schedule. The immunogenicity was usually sufficient and there was no evidence of a relevant aggravation of the underlying disease. Recommendations for the clinical practice are given also considering data beyond pediatric rheumatology; however, a final benefit-risk assessment is not yet possible.
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Affiliation(s)
- K Minden
- Universitätskinderklinik Charité, Campus Virchow, Otto-Heubner-Centrum, SPZ, Deutsches Rheuma-Forschungszentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland,
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