Challenges in achieving consensus for vaccination with live attenuated vaccines in children with rheumatological disease – the variability of vaccination practices across the globe

Introduction: Due to the paucity of randomised controlled studies concerning vaccination in children with rheumatic diseases, the level of evidence for recommendations for vaccinations in these children is low. Booster doses of live attenuated vaccines might be considered in children with rheumatic diseases treated with immunosuppressive therapy, but data from multicentre studies are lacking. Moreover, national vaccination programs, parental obligation to vaccinate their children and vaccine coverage rates vary greatly among countries. Objectives: To highlight differences in the current national vaccination policies, and to develop a platform for future multicentre initiatives for uniform vaccination practices for children with rheumatic diseases treated with immunosuppressive drugs. Methods: The PReS Vaccination working group was formed during the 2017 PReS meeting in Athens. Paediatric rheumatologists from 34 countries were invited to participate. Results: Data were collected from 25 countries who responded. Vaccinations are mandatory in 12/21 European countries (Croatia, Czech Republic, France, Greece, Hungary, Italy, Latvia, Poland, Serbia, Slovakia, Slovenia, Ukraine). The vaccination schedules and coverage differ among countries. The first MMR vaccine is recommended at 11-15 months- of-age in all countries and most recommend the second dose before 2 years-of-age or at 6 years ; however in Spain it is at 2-4 years, in the UK at 3-5 years, and in Hungary, The Netherlands, Estonia, Norway, Poland and Slovakia at the age of 9 years or later. Mandatory programs, as compared to optional vaccination, do not always ensure higher coverage. For example, in Australia, Israel, The Netherlands and Norway where vaccinations are optional, the vaccination rate is high, at around 95%. However, coverage for MMR fell below 95% in Croatia, Czech Republic, Serbia and Slovenia, where vaccination is mandatory. Vaccinations were optional in France and Italy ; however, due to low coverage, they are now mandatory. Conclusion: There are considerable differences amongst countries in vaccination programmes, coverage, and in parental obligation to vaccinate their child. A powerful anti-vaccine campaign has gained momentum in many countries and has resulted in a significant drop in vaccination coverage to a level that is no longer sufficient for herd immunity. This is especially dangerous for children with rheumatic diseases on immunosuppressive therapy. Our future goals are to prospectively examine the outcomes of live vaccination in children with rheumatic diseases who are treated with immunosuppressive drugs and hopefully to demonstrate that booster doses of live attenuated vaccines are safe and protective.