title: Efficacy and Safety of Vaccination in Pediatric Patients with Systemic Inflammatory Rheumatic Diseases: a systematic review of the literature.
abstract: BACKGROUND
  Children and adolescents with systemic rheumatic diseases have an increased risk of infections. Although some infections are vaccine-preventable, immunization among patients with juvenile rheumatic diseases is suboptimal, partly due to some doubts that still persist regarding its efficacy and safety in this patient population.
  
  
  OBJECTIVE
  To review the available evidence regarding the immunological response and the safety of vaccination in children and adolescents with systemic inflammatory rheumatic diseases (SIRD).
  
  
  METHODS
  A systematic review of the current literature until December 2014 using MEDLINE, EMBASE and abstracts from the American College of Rheumatology and European League Against Rheumatism congresses (2011-2014), complemented by hand search was performed. Eligible studies were identified and efficacy (seroprotection and/or seroconversion) and safety (reactions to vaccine and relapse of rheumatic disease) outcomes were extracted and summarized according to the type of vaccine.
  
  
  RESULTS
  Twenty-eight articles concerning vaccination in pediatric patients with SIRDs were found, that included almost 2100 children and adolescents, comprising nearly all standard vaccinations of the recommended immunization schedule. Children with SIRDs generally achieved seroprotection and seroconversion; nevertheless, the antibody levels were often lower when compared with healthy children. Glucocorticoids and conventional disease-modifying anti-rheumatic drugs do not seem to significantly hamper the immune responses, whereas TNF inhibitors may reduce antibody production, particularly in response to pneumococcal conjugate, influenza, meningococcal C and hepatitis A vaccine. There were no serious adverse events, nor evidence of a relevant worsening of the underlying rheumatic disease. Concerning live attenuated vaccines, the evidence is scarce, but no episodes of overt disease were reported, even in patients under biological therapy.
  
  
  CONCLUSIONS
  Existing literature demonstrates that vaccines are generally well tolerated and effective in stable SIRD patients, yet antibody titers are frequently lower than in healthy controls. There is some evidence that biological therapy could hamper the immune response. Data on safety of live attenuated vaccines is limited. Although the available literature covers most vaccines included in the national immunization plan, there is a need for more information regarding new vaccines and new anti-rheumatic therapies.
authors.affiliation: Hospital Garcia de Orta.
authors.forename: Sandra
authors.initials: S
authors.lastname: Sousa
authors.affiliation: Hospital Garcia de Orta.
authors.forename: Ana Catarina
authors.initials: AC
authors.lastname: Duarte
authors.affiliation: Hospital Garcia de Orta.
authors.forename: Inês
authors.initials: I
authors.lastname: Cordeiro
authors.affiliation: Centro Hospitalar e Universitário de Coimbra.
authors.forename: Joana
authors.initials: J
authors.lastname: Ferreira
authors.affiliation: Hospital de Santa Maria, Centro Hospitalar Lisboa Norte.
authors.forename: Maria João
authors.initials: MJ
authors.lastname: Gonçalves
authors.affiliation: Hospital Infante D. Pedro, Centro Hospitalar do Baixo Vouga.
authors.forename: Tiago
authors.initials: T
authors.lastname: Meirinhos
authors.affiliation: Hospital de São João, Centro Hospitalar de São João.
authors.forename: Teresa Martins
authors.initials: TM
authors.lastname: Rocha
authors.affiliation: Hospital de Santa Maria, Centro Hospitalar Lisboa Norte.
authors.forename: Vasco C
authors.initials: VC
authors.lastname: Romão
authors.affiliation: Hospital Garcia de Orta.
authors.forename: Maria José
authors.initials: MJ
authors.lastname: Santos
mesh_terms: D000293:Adolescent; D002648:Child; D006801:Humans; D007249:Inflammation / Q000150:complications*; D012216:Rheumatic Diseases / Q000150:complications*; D014611:Vaccination / Q000009:adverse effects; D014612:Vaccines / Q000276:immunology*
chemical_list: D014612:Vaccines