Vaccinations in Pediatric Rheumatic Diseases: Guidance for General Practitioners

Children with rheumatic diseases, such as juvenile idiopathic arthritis or pediatric lupus, often have weakened immune systems due to the condition itself or the medications they take, including corticosteroids, methotrexate, and biologics. This increased vulnerability makes them more susceptible to severe infections from vaccine-preventable diseases. Therefore, routine immunizations are crucial for the health of these patients.

Global experts in rheumatology and immunization strongly recommend that children with autoimmune rheumatic diseases receive all recommended vaccines according to the standard schedule. Only a few exceptions are made for live vaccines when necessary. Research has demonstrated that these vaccines are safe and do not typically trigger disease flare-ups.

As a general practitioner, you play a vital role in protecting these children by coordinating with specialists regarding the timing of vaccinations and any necessary precautions. Below is a comprehensive overview tailored for GPs, highlighting key points regarding vaccine safety, scheduling, and specific situations for quick reference.

Vaccine Safety on Immunosuppressive Therapy

Inactivated (non-live) vaccines are very safe for children with weakened immune systems. These vaccines contain killed pathogens or fragments, which means they cannot cause infections in the patient. Research shows that non-live vaccines do not worsen the activity of rheumatic diseases. For example, inactivated vaccines for flu, pneumococcus, and hepatitis have been safely administered to children with juvenile arthritis without increasing the frequency of disease flare-ups. The benefits of vaccination far outweigh any theoretical risks; preventing illnesses like measles, chickenpox, or influenza is critical for a child whose immune system is compromised. Furthermore, immunization significantly lowers the risk of severe infections during immunosuppressive therapy, which can be crucial for a child’s health.

• Efficacy considerations: It is important to note that while inactivated vaccines are considered safe, patients on immunosuppressants may have a reduced immune response. High-dose steroids or biologics can lower the effectiveness of these vaccines, which means that the child might not develop strong immunity. Nonetheless, it is essential to administer inactivated vaccines on schedule because some protection is better than none. In some instances, additional doses or boosters may be recommended to ensure adequate protection. For example, a follow-up pneumococcal polysaccharide vaccine (PPSV23) might be advised after the routine conjugate series for a child with significant immunosuppression. Additionally, a repeat hepatitis B titer check can help determine if an extra dose is necessary.
• Influenza vaccination is strongly recommended for immunosuppressed children aged 6 months and older. Children should receive the complete PCV13 series and the PPSV23 at the appropriate age if they have asplenia or other risk factors. These recommendations are made because immunosuppression increases the risk of severe outcomes from influenza and invasive pneumococcal disease. Other vaccines, such as Hib, meningococcal, and hepatitis A/B, should be kept up to date, as these children are more vulnerable to complications. There is no evidence that these vaccines trigger relapses of rheumatic disease in clinically stable individual patients.

The bottom line is that you should not withhold inactivated vaccines due to fear of flare-ups. Current evidence and guidelines support timely vaccination for children with rheumatic diseases. By preventing infection, you also help avoid triggers for disease flare-ups, as infections can provoke them.

Live vs. Inactivated Vaccines: Key Differences and Precautions

It is crucial to differentiate between vaccine types when treating immunosuppressed pediatric patients:

• Inactivated vaccines: They contain killed organisms or components (protein subunits, toxoids, mRNA, etc.). Since they cannot replicate, they cannot cause disease in the recipient. Examples include inactivated polio (IPV), diphtheria-tetanus-pertussis (DTaP/Tdap), injectable flu vaccine (IIV), as well as hepatitis A and B, HPV, pneumococcal, Hib, and COVID-19 vaccines (all current COVID-19 vaccines are non-live, such as mRNA or viral vector, and carry no risk of infection). These are safe to administer even during immunosuppressive therapy. It’s important to advise that the child’s immune response may be lower than usual and to follow up on titers or boosters if necessary.
• Live attenuated vaccines Contain a weakened form of the pathogen that can replicate to a limited degree. Examples include measles-mumps-rubella (MMR), varicella (chickenpox), the MMRV combination, rotavirus (oral), intranasal influenza (LAIV nasal spray), oral polio vaccine (OPV, where applicable), yellow fever, BCG, and oral typhoid. These vaccines rarely cause illness and provide strong immunity in a healthy individual. However, live vaccines can pose safety concerns in an immunosuppressed child: the weakened virus or bacteria might replicate uncontrollably and lead to disease. For example, disseminated vaccine-strain varicella or measles infection poses a risk in a child receiving high-dose steroids or biologics. Thus, live vaccines are generally contraindicated for patients with significant immunosuppression.

Vaccination guidelines for immunocompromised patients (Australian Immunisation Handbook). In immunosuppressed individuals: Administer all indicated inactivated vaccines (e.g., influenza, pneumococcal) and additional doses if necessary; avoid live vaccines in cases of severe immunocompromise. Live vaccines such as MMR, varicella (MMRV), rotavirus, zoster, and yellow fever may be given if immunosuppression is mild (consult specialist advice). Live BCG and oral typhoid vaccines are not administered. Household contacts should be fully vaccinated (including all their live vaccines) to protect the immunocompromised child.

Key point: Do NOT administer live-attenuated vaccines to severely immunosuppressed children. This includes those on high-dose corticosteroids, biologic agents (e.g., anti-TNF, rituximab, etc.), cytotoxic drugs, or those with severe primary immunodeficiency. In these cases, live vaccines should be deferred until the immune status improves (see timing below). Administering a live vaccine to a significantly immunocompromised host could lead to uncontrolled replication of the vaccine strain and serious illness. For example, the live intranasal flu or varicella vaccine could cause a disseminated infection in such patients, so they should be avoided.

Children with mild immunosuppression can still receive certain live vaccines under careful supervision. Guidelines recognize that immunization may be beneficial if the child’s immune suppression is not severe. For example, MMR (measles-mumps-rubella) and varicella vaccines have been administered safely to some children on low-dose methotrexate or stable low-dose immunosuppressants. EULAR’s 2021 task force notes explicitly that an MMR booster or varicella vaccine may be given under certain conditions to immunosuppressed pediatric patients at high risk of wild infections. Likewise, the Australian handbook states that “less severely immunocompromised patients may be able to receive live vaccines, depending on their level of immunocompromise” (such as MMR, MMRV, rotavirus, zoster, yellow fever). This decision should always involve the child’s rheumatologist or immunologist. As the GP, consult the specialist before administering any live vaccine to a child undergoing immunosuppressive therapy. If necessary (e.g., during a local measles outbreak or before travel), the specialist may recommend temporarily holding medications, checking lymphocyte counts, or administering the vaccine in a monitored hospital setting.

Household contacts: Encourage family members and close contacts to be fully vaccinated, including annual flu shots and other routine vaccines. This “cocooning” strategy protects the immunosuppressed child by reducing exposure to infections. It is safe for healthy contacts to receive live vaccines (MMR, varicella, nasal flu, etc.) as these do not shed significant viruses that could harm the patient (with rare exceptions, like avoiding contact with diaper changes after the infant rotavirus vaccine for about 1-2 weeks). Immunizing siblings and classmates is one of the best ways to protect a vulnerable child. If a household member develops a rash after a live vaccine (e.g., varicella), contact the specialist; however, such rashes are usually mild, non-infectious, or minimally contagious.

Summary: Use inactivated vaccines freely—they are safe and essential. Use live vaccines with caution. Generally, avoid them during significant immunosuppression, but consider them case-by-case if immunosuppression is minimal. The risk of disease is high, so consult with the rheumatologist. Avoid shielding the child from infection and seek specialist input when uncertain.

Timing of Vaccination Relative to Disease Activity and Treatment

Timely administration can greatly enhance vaccine safety and effectiveness. Below are practical guidelines for scheduling vaccinations in children with rheumatic diseases:

• Before starting immunosuppressive therapy, Ensure the child is current on vaccinations before beginning a new immunosuppressive medication. This is particularly crucial for live vaccines. For instance, if a child with new-onset juvenile arthritis is about to start a biologic (e.g., etanercept), aim to administer any due live vaccines (such as the MMR or varicella booster) at least 4 weeks before starting the biologic. Ideally, inactivated vaccines should be given at least 2 weeks before therapy to allow time for immunity to develop. The CDC and IDSA guidelines recommend a minimum of 4 weeks before immunosuppressive therapy for live vaccines and 2 weeks for non-live vaccines. In practice, do what is feasible: if there is a window of opportunity (e.g., the diagnosis is made and medications will start in a month), utilize that time to update immunizations. Do not excessively delay urgent rheumatologic vaccine treatment; managing the disease is also essential. If therapy needs to begin immediately, plan vaccinations around it for later.
• During ongoing immunosuppressive treatment: Vaccinations can and should continue while the child is undergoing therapy, emphasizing administering inactivated vaccines on schedule. The ideal scenario is to vaccinate when the rheumatic disease is quiescent or stable, meaning there are no severe flares. Primary care physicians should communicate with the pediatric rheumatologist to determine the best vaccination timing. Consider scheduling vaccines mid-cycle or between doses for a child on cyclic treatments, such as monthly IV biologic infusions or weekly MTX injections. For instance, if a child receives a biologic infusion every four weeks, administering an inactivated vaccine two weeks after the infusion, when drug levels may be lower, could slightly enhance the immune response. Similarly, avoid vaccinating during the peak of a severe flare or while the child is on very high steroid doses unless it is necessary. Although it’s not dangerous to vaccinate during a flare, the child may feel unwell or experience a weaker response. If disease activity is high and a vaccine (not urgent) can be postponed briefly, waiting until the child’s condition improves or the steroid dose is reduced is reasonable. Conversely, if there is an urgent need—such as an influenza outbreak—do not delay vaccination solely because of active disease; take the necessary precautions but proceed with the vaccination to protect the child.
• Holding or adjusting medications around vaccinations: In some cases, temporarily pausing an immunosuppressive drug can enhance vaccine effectiveness. Rheumatologists may consider this if the child’s rheumatic disease is well-controlled. Methotrexate (MTX) is a prime example: Holding MTX for 1–2 weeks after an influenza or COVID-19 vaccine has been shown to boost antibody responses without significantly increasing arthritis activity in adult studies. ACR guidelines recommend holding methotrexate for 2 weeks after a flu shot if disease activity permits. As a GP administering the flu vaccine, you can coordinate with the rheumatologist on whether the family should skip the next one or two MTX doses. ACR guidance states: “Non-rheumatology providers (e.g., general pediatricians) are encouraged to administer the influenza vaccination and then consult the patient’s rheumatology provider about holding methotrexate.” This emphasizes that missing a vaccination opportunity is riskier than a short MTX pause, provided the rheumatologist agrees.
• Other medications: The strategy for rituximab (a B-cell depleting agent) differs because it significantly impacts vaccine response. Ideally, time vaccinations for when the next rituximab dose is due, then postpone that infusion by about 2 weeks after the vaccine, or if feasible, vaccinate several months following the last rituximab dose. (Rituximab leads to prolonged B-cell suppression – studies suggest waiting at least 6 months post-rituximab for optimal vaccine responses.) For high-dose systemic steroids, as mentioned, defer elective vaccines until the dosage is below 20 mg/day of prednisone (or equivalent), as very high doses can hinder vaccine responses. Short-term steroid bursts (e.g., a 2-week course) are not absolute contraindications for vaccines, but the immune response may not be optimal – consider re-checking titers later or re-immunizing. NSAIDs and hydroxychloroquine do not interfere with vaccination and are not required to be stopped. 
• Continuously individualize: These decisions (holding meds) are case-by-case. Never stop or skip a dose without the rheumatologist’s input. The specialist will weigh the risk of a disease flare against the benefit of improved vaccine response. If the rheumatic disease is active, they may choose not to hold any medication and proceed with vaccination (especially for critical vaccines like influenza) while continuing therapy. They might plan a brief drug interruption in other situations (stable low disease activity). Your communication with the specialist is key to making these adjustments safely.
• If the child’s rheumatic disease is very active: When the patient is experiencing a flare or undergoing intensive immunosuppression (e.g., pulse steroids), you may wish to postpone non-urgent vaccines for a brief period. This is primarily to ensure the child is healthy enough to manage potential vaccine side effects and to optimize the vaccine’s effectiveness. For example, a child on 60 mg of prednisone with a severe lupus flare could reasonably delay a scheduled HPV or HepA vaccine by a few weeks until the steroid dosage is reduced. Give the postponed vaccine as soon as the child’s condition allows – don’t let it slip through the cracks. However, if an urgent public health need arises (e.g., measles exposure or a tetanus-prone wound), administer the necessary vaccine (or passive immunization) regardless of disease activity while taking appropriate precautions. The rheumatology team may implement strategies to reduce risk (such as prophylactic antibodies or temporarily increasing immunosuppression to counter a potential flare triggered by the infection or vaccine). The guiding principle is to keep the child up-to-date on immunizations without compromising their rheumatic disease management.
• Regular review and planning: Make vaccine status routine during clinic visits. For GPs, review the child’s immunization record and current medications during each chronic care appointment (or at least once a year). Coordinate with the rheumatologist regarding any upcoming needs. Many pediatric rheumatology teams conduct an annual vaccine review as part of their care (EULAR recommends an annual vaccination status assessment by the specialist). You can replicate this practice in primary care. Simply asking, “Are any vaccines due or coming up?” at each visit can facilitate planning. Suppose a live vaccine is expected next year (for example, the second varicella dose), and you anticipate that the child may start a more potent drug soon. In that case, early discussions can assist in timing it appropriately. Encourage families to maintain and share an updated immunization card with all providers.

School and Daycare Considerations

Children with pediatric rheumatic diseases should be able to attend school or daycare safely and without discrimination, and vaccination contributes to this goal. As a GP, you might need to assist with medical documentation for school requirements:

• Routine vaccines and school entry: Most jurisdictions require proof of certain immunizations (MMR, varicella, polio, etc.) for enrollment. Nearly all routine childhood vaccines can be administered to children with rheumatic diseases, as discussed. Ideally, by the time school starts, the child will have received these vaccines or have a plan for any deferred doses. Ensure the child’s vaccination record is updated in their chart; double-check if any doses were missed due to immunosuppression.
• Medical exemptions for live vaccines: If a child cannot receive a required vaccine on schedule due to immunosuppressive therapy (for example, the varicella vaccine might be deferred because of high-dose steroids or biologics), you can provide a medical exemption letter for the school. All educational systems have provisions for medical contraindications. Typically, a letter on official letterhead stating: “[Child’s Name] is under my care for [rheumatic condition]. Due to immune-suppressing treatment, [vaccine] is temporarily contraindicated at this time” will suffice. Schools may accept this in place of the vaccine record for that immunization. Make it clear that this is a temporary delay and that the vaccine will be administered when it is safe – this demonstrates that you are adhering to guidelines rather than simply opting out. For instance, “Varicella vaccine to be given when immunosuppression allows.”
• Exclusion during outbreaks: Advise parents and school nurses that if there is an outbreak (such as measles or chickenpox in the school and the child is non-immune due to not receiving a live vaccine), the child may need to stay home for safety. This is typically a short-term precaution. As the GP, you might be consulted about providing preventive measures (e.g., varicella zoster immune globulin or measles Ig). Collaborate with public health authorities on the best approach.
• Cocooning in school: This reinforces overall good practices. The child’s classmates and teachers should be vaccinated according to standard recommendations, which most schools enforce anyway. This herd immunity protects everyone, especially your patient. Fortunately, school vaccine requirements in many regions ensure that most children’s peers are immunized, thereby reducing the risk of an outbreak on campus.
• Healthy habits: Encourage the family to have the child practice regular infection-prevention habits at school, such as hand hygiene, wearing masks during flu season when necessary, avoiding close contact with sick peers, etc. These measures provide an additional layer of protection alongside vaccination.

In summary, children on immunosuppressive therapy can usually attend school. Just be sure to document any missing vaccines with exemptions and have a plan to update them later. Maintaining open communication with school health officials will help the child stay in school safely. Remind schools that these are medical exemptions, not philosophical ones, and that the child is being managed according to best medical practices. This typically ensures full cooperation.

Travel Vaccinations and Special Situations

Travel can present additional challenges for immunocompromised children, as they may encounter diseases that are not common at home and may sometimes need live vaccines.

• Pre-Travel Planning: If a family plans international travel, start the conversation early (at least 4–6 weeks in advance). As the GP, conduct a basic travel risk assessment, then involve a travel medicine clinic or infectious disease specialist as needed. Identify which additional vaccines may be recommended for the destination, such as hepatitis A, typhoid, yellow fever, Japanese encephalitis, meningococcal ACWY, etc. Many of these (hepatitis A, injectable typhoid, meningococcal) are inactivated and can be administered safely. Schedule them well before departure. If the child is on a medication regimen, plan to provide any necessary shots at least 2 weeks (for inactivated) or 4 weeks (for live) before a significant increase in immunosuppression, whenever possible. Additionally, ensure the child’s routine immunizations (MMR, polio, etc.) are updated before travel—measles outbreaks, for example, are more common in certain regions, so the child must be safeguarded by prior vaccination or appropriate measures.
• Yellow fever and other required live vaccines: The yellow fever (YF) vaccine is a live vaccine and is generally contraindicated for immunosuppressed individuals due to the risk of severe adverse reactions. Many countries in Africa and South America require YF vaccination for entry. In these cases, the approach is to provide a medical waiver. The WHO International Health Regulations allow travelers to present an official “Certificate of Medical Contraindication to Vaccination” if a vaccine like YF cannot be administered for medical reasons. As a GP or travel clinic physician, you would complete and sign the waiver section of the International Certificate of Vaccination (the “yellow card”) or provide a letter on letterhead explaining the contraindication. Most countries honor such waivers, although travelers should know they may face additional entry screening. Counsel the family that they must be diligent about protecting against mosquitoes in YF-endemic areas (such as using repellents and bed nets) instead of receiving the vaccine. Another example is the BCG vaccine (for TB), which is also live; an immunosuppressed child should not receive it if required or recommended. They may need avoidance strategies or TB prophylaxis if they are at high risk.
• Permissible live vaccines for travel: Certain live vaccines may be advised (although not legally mandated) for specific trips—such as live attenuated Japanese encephalitis or oral typhoid (in select countries). Generally, if a child is severely immunocompromised, these vaccines should be avoided, and alternative preventive measures (like standby antibiotics for typhoid or strict food precautions) should be implemented. If the child’s immune suppression is mild and the risk of infection during the trip is significant, a specialist might carefully administer a live vaccine. For example, a physician might consider giving the live oral typhoid vaccine to a child on low-dose MTX with well-controlled disease if traveling to a high-risk area for typhoid, but only after discussing the risks and ensuring close follow-up. These are nuanced decisions best addressed with input from infectious disease and rheumatology specialists.
• Post-travel follow-up: Ensure the child receives any necessary post-exposure vaccines or immune globulins (such as rabies vaccines if they experienced an animal bite) appropriately, as the child’s immune response may be suboptimal.
• Other precautions: Guidance on safe food and water practices (to prevent diarrheal illness, which can be more severe in immunocompromised individuals), malaria prophylaxis if needed (as malaria can be severe in an immunosuppressed child), and travel health insurance or medical evacuation plans. Prepare a travel letter summarizing the child’s condition, medications (especially immunosuppressants or injectable biologics they may carry), and vaccination contraindications or exemptions. This can be invaluable if they need medical care while traveling abroad. Additionally, remind the family to bring an updated vaccine record when they travel.

In summary, immunosuppression doesn’t prevent travel but requires careful preparation. Work closely with the family and specialists to ensure the child receives the necessary, safe vaccines and documentation. If a needed vaccine is live and unsafe to administer, provide official waivers and maximize other protective measures. Families will appreciate clear guidance that enables their children to travel safely.

Coordinating Care with Rheumatology and Other Specialists

Managing vaccinations for a child with a rheumatic disease requires teamwork. As the GP or pediatrician, you serve as the central point for preventive care and can coordinate among providers.

Communication is key: Keep an open line of communication with the child’s pediatric rheumatologist about vaccination plans. If you’re uncertain about the safety of a vaccine (especially live vaccines), consult the rheumatologist before giving it. A quick phone call or EMR message can often clarify whether the child is in an appropriate window for a particular vaccine. Conversely, rheumatologists might depend on you to administer the vaccines since many specialty clinics do not provide them on-site. Ensure you receive clear instructions if the rheumatologist states, “It’s okay to give the varicella vaccine next month; we’ll hold methotrexate.” Confirm who will inform the family about holding the medication – you often reinforce those instructions.

Regularly update vaccine status: As mentioned, incorporate vaccine review into the child’s routine visits. Encourage the family to bring their immunization record to each appointment so you can identify any missing vaccines. If the child sees multiple providers, records can sometimes become fragmented – you may be the one to notice that, for example, the second dose of HPV was never administered amid all the other medical concerns. Collaborate: the rheumatologist may keep a vaccine plan in their notes; seek access if possible. If you provide a vaccine, send a note or update to the specialist so they know what’s been given (this assists them in timing any medication) adjustments).

Unified messaging: The family must receive a consistent message from all providers emphasizing that vaccines are essential and recommended. Occasionally, specialists may defer to the GP, while GPs defer to specialists, leading to confusion for families who may feel that no one is certain. To prevent mixed messages, proactively discuss and agree on a plan with the rheumatologist. For instance, you might say, “I’m planning to administer the inactivated flu shot today; do you have any concerns or special instructions?” This way, when you inform the parents of the plan, you can confidently state it’s a consensus. A united front of medical advice is reassuring if parents are anxious (typical with these complex cases).

Patient/parent education: Offer clear, empathetic explanations to the family. Many parents worry about vaccines causing flares or side effects in their children. You can clarify that studies indicate vaccines do not worsen rheumatic disease and that the greater risk lies in not vaccinating (the child could contract a severe infection while on immunosuppressants). Explain any timing strategy, such as: “We’ll wait a month for this shot because the steroid dose is very high, and the vaccine might not be effective. This is according to expert guidelines.” Such explanations help parents understand that you’re tailoring the schedule for their child’s benefit, not neglecting it. Please encourage them to voice their concerns and discuss them with you and the rheumatologist. It’s also beneficial to remind them that the healthcare team agrees – for example, “Your rheumatologist and I both recommend this vaccine now.”

Maintain a checklist: For complex patients, it may be helpful to keep an ongoing checklist in the chart indicating which vaccines are pending, which are currently contraindicated, and plans for catching up. For instance, “Varicella #2—on hold, to administer in summer 2025 if off high-dose steroids.” This can help prevent anything from slipping through the cracks over years of care treatment.

Engage an immunology and infectious disease specialist if needed: If there’s still uncertainty (especially regarding novel vaccines or unusual circumstances), do not hesitate to consult with a pediatric infectious disease or immunology expert. They can offer further guidance on vaccination for immunocompromised patients (such as passive immunizations or antibody titer evaluations after vaccination). This multidisciplinary approach is often utilized in hospital-based clinics, but you can replicate it by reaching out for a curbside consult.

By collaborating closely with the specialist team and the family, you ensure the child receives maximum vaccine protection with minimal risk. The shared goal is to keep the child healthy and free from infections so they can focus on growth, school, and managing their rheumatic condition.

Key Takeaways for Busy Clinicians

Don’t wait—vaccinate! Children with rheumatic diseases need routine immunizations, primarily inactivated vaccines, and must be on schedule to prevent serious infections. Their immunosuppressed status increases their need for vaccines, not decreases it.

Inactivated vaccines are safe, even during immunosuppressive therapy. They do not cause disease flares in stable patients. Administer flu shots annually and ensure pneumococcal, Hib, hepatitis, HPV, and other vaccines are up to date.

Live vaccines (MMR, varicella, intranasal flu, etc.) are generally contraindicated if the child is on high-level immunosuppression. Unless in unique low-risk scenarios, avoid live vaccines until the rheumatologist clears. If needed (e.g., an MMR booster) and immunosuppression is mild, plan it carefully with specialist input.

Time vaccines strategically: Ideally, administer vaccines before starting immunosuppressive therapy (at least 4 weeks before live vaccines and at least 2 weeks for inactivated ones). During treatment, vaccinate when the disease is quiescent or mid-cycle if possible. Avoid scheduling non-urgent vaccines during severe flares or periods of very high steroid use (wait until the dose is lower, if necessary) feasible).

Coordinate medication holds: For medications like methotrexate, consider holding for about two weeks after vaccination to enhance the response (if the disease is stable). Always discuss this with the rheumatologist. Do not discontinue any immunosuppressive drug without approval, but be mindful of recommendations to pause or time doses around vaccinations (e.g., delay rituximab doses around vaccines).

Document and communicate: Maintain a clear record of the child’s vaccination plan. Provide medical exemption letters for any required vaccines postponed due to immunosuppression (schools will accept this). Inform schools that the child is temporarily exempt for medical reasons, and ensure there is a plan to vaccinate when possible.

Protect through the community: Advise that household members and close contacts be fully vaccinated—this indirect protection is crucial. Most live vaccines are safe for contact and will not harm the patient, so siblings should receive their varicella, MMR, and flu vaccines, etc.

Exceptional cases: Plan travel early. If the child is immunosuppressed, avoid live vaccines for travel (use waivers for yellow fever, etc.) and emphasize precautions (such as preventing mosquitoes and ensuring food safety). In outbreak situations, coordinate promptly with public health authorities (e.g., administer IG or antivirals if the child is exposed and not immune).

Collaborate with specialists: If you have concerns about a vaccine, contact a rheumatologist or an infectious disease specialist. A brief discussion can clarify issues related to timing or safety. Sharing decision-making with the family and care team will lead to the best outcome: protecting the child from infections while managing their rheumatic disease.

Adhere to these guidelines and employ a team-based approach to manage vaccinations for children with rheumatic diseases effectively. This proactive, coordinated care will assist patients in avoiding preventable infections and leading healthier lives. Vaccination is a vital component of their overall treatment plan, and as the GP, you play a key role in its success.

References:

1. Heijstek MW, et al. MMR vaccination in JIA patients: no increase in disease activity. Ann Rheum Dis. 2007. 

2. Australian Immunisation Handbook – Vaccination for immunocompromised persons (2020).  

3. Centers for Disease Control and Prevention. General Best Practices: Altered Immunocompetence. (2022) 

4. EULAR/PRES 2022 Recommendations for Vaccination in Pediatric Rheumatic Diseases 

5. American College of Rheumatology (ACR) 2022 Vaccination Guideline Summary 

6. Canadian Paediatric Society. Immunization of immunocompromised children: key principles. (2018) 7. World Health Organization. Yellow Fever – International Travel and Health (2019).