Getting a child ready for preschool, kindergarten or middle school usually requires immunizations. In fact, laws in all 50 states mandate that children can't attend school unless their immunization status is up-to-date. But if your child has arthritis or another rheumatic disease, even routine immunizations may not be so, well, routine.
Vaccines are important for controlling disease, but doctors have had concerns about immunizing children with arthritis and other rheumatic diseases for years, says Harry L. Gewanter, MD, a pediatric rheumatologist at Pediatric and Adolescent Health Partners in Richmond, Va.
There are several reasons; two of biggest are that some vaccines may not work for them and that they might even cause the child to catch the disease the vaccine was aimed at preventing.
Surprisingly, new research is showing that perhaps vaccines once deemed off-limits for children with arthritis might not be off the table. However, Dr. Gewanter says it's important to be cautious. Learning how vaccines work and talking to your child’s doctor about what might be right for her is the smartest course of action.
A Cautious History
The traditional apprehension about vaccines for children with arthritis is based on the science behind vaccines. For vaccines to be successful the recipient must have a healthy immune system. Vaccines work by exposing a person to a small dose of a virus or bacteria so their immune system will learn to recognize it and be ready to fight it off, if exposed to it later. “They trick the immune system into thinking it has been exposed to that germ, and it responds as if it had encountered the real (wild) germ,” says Dr. Gewanter.
While less than 10 percent of children may typically have adverse effects from any vaccine (e.g., fever, rash, aches, etc.), the potential for a more serious problems exist if the child’s immune system is suppressed by their arthritis and/or medications. Corticosteroids, disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate and biologic response modifiers (biologics) are examples of medications that can alter the immune system’s response to an immunization.
Whether caused by arthritis or its treatment, if your child’s immune system is altered it may not mount the proper response to a vaccine. That could cause vaccines to fail and not prevent disease if he is ever exposed; or it could result in him possibly developing the disease the vaccine was designed to prevent. It may even cause an arthritis flare.
Vaccines, for the most part, can be broken up into two main categories – live attenuated and inactivated. In the case of live attenuated vaccines, the vaccine recipient is injected with a live but weakened strain of a disease, virus or bacteria.
Dr. Gewanter says the greatest chance of a vaccine not working or causing the disease it's meant to prevent is with these live attenuated vaccines. They include those given to prevent chicken pox (varicella); measles, mumps, rubella (MMR); and rotavirus; and the nasal flu vaccine, FluMist.
Although you might need to be cautious about giving your child live vaccines, he will likely be able to get inactivated vaccines. They are made from killed viruses or bacteria, or parts of these killed diseases. Inactivated vaccines make up the bulk of required vaccines and are safe and effective for all children, including those with arthritis or who are on various medications. They are important for your child to receive because they will help protect her and those around her.
Weighing the Risk
While there are reasons for exercising caution when it comes to live vaccines, increasingly, research is starting to put some of the fears about them to rest. For example, in a study published a few years back in the Annals of the Rheumatic Diseases, researchers from the Netherlands found no overt measles infection nor increase in arthritis activity in 314 children with juvenile arthritis given the MMR vaccination.
Another study published earlier in the same journal by researchers in Turkey showed that children with juvenile arthritis produced an adequate response to the hepatitis B vaccination – even if they were receiving immunosuppressive therapy.
Although these and other studies have shown that children with arthritis usually respond well to most vaccines, some pediatric rheumatologists remain wary of giving live attenuated vaccines to children on immunosuppressive therapy, especially biologic agents and corticosteroids.
“It may be OK, [but] we just don’t have enough data yet to say for sure that it is sufficiently safe and effective,” says Dr. Gewanter. “So, for a lot of these kids we will choose to hold those vaccines.”
But for optimal protection of your child and those around him or her, it’s important to get needed immunizations as soon as your child’s doctors thinks it’s safe, he says.
“Immunizations are probably the greatest medical advance we have,” says Dr. Gewanter. “They are the only true preventive medicine out there. The diseases we are immunizing children against can be devastating in healthy individuals, much less someone with a chronic disease. Further, since many people with arthritis will have a flare of their disease during or just after an illness, it is worth it to try to prevent as many of these diseases as possible.”
If Vaccination Is Off-limits
Even though vaccines are required for children to attend school, forgoing certain vaccinations doesn’t mean forgoing school. All 50 states have a medical exemption for children whose doctors feel they should not have certain immunizations, says Dr. Gewanter.
If you and your child’s doctor decide that a particular vaccination is not in his best interest, the doctor will need to fill out an exemption form, which typically states the reason for the exemption, a specific vaccine or vaccines the child should not receive and the length of time the child may need to go without the immunization.
Forgoing an immunization doesn’t necessarily put your child at high risk of disease because there are precautions you can take, says Dr. Gewanter. Ensuring that family members and others your child interacts with are up-to-date on their vaccines – such as influenza and chickenpox – can lower the disease risk for your child who is not immunized.
If your child does become ill, it’s important to get medical care as soon as possible. Prompt treatment improves the outcome for virtually any disease. For flu and chickenpox, there are antiviral medications that help if they are started in the first 48 hours after the first symptoms appear. In other situations, it's possible to use medications to try to prevent catching the disease after an exposure. It's also important to make sure that all of your child’s physicians know about every medication being used so your child isn't immunized by mistake.