Updated: Vaccination of children with AIIRD

This is the lay version of the EULAR recommendations for vaccination of children with an autoimmune rheumatic disease. The original publication can be downloaded from the EULAR website: www.eular.org.


EULAR gives advice to doctors, nurses, and patients about the best way to treat and manage diseases. Health professionals and patients worked together to develop these recommendations on the use of vaccines in children with an autoimmune or inflammatory rheumatic disease (pedAIIRD). The patients in the team ensured that the patient point of view was included.

What do we already know?

People of all ages with autoimmune or inflammatory rheumatic diseases (AIIRD) have an increased risk of infections compared to people in the general population. This is partly caused by the disease itself, but can also be caused by treatment with drugs that change or suppress the way the immune system works. Many disease-modifying antirheumatic drugs (DMARDs) used in people with AIIRD work by damping down the effects of inflammation, i.e. they dampen the immune response.

Children are usually offered a series of vaccines as part of an established immunization program. This will vary slightly from country to country, but usually includes vaccination against common infectious diseases that can otherwise cause major or long-term harm. However, children with pedAIIRD may need some additional vaccinations, and there are also some specific considerations around timing in relation to both other medicines they may be using, and to how active their disease is.

What do the recommendations say?

In total, there are six overarching principles and seven recommendations. The principles say that the vaccination status and need for any additional vaccines must be assessed yearly by the treating specialist in paediatric AIIRD, and recommendations generally follow the national immunization program. Ideally, children should receive vaccines while their disease is quiet, or disease activity is low. Where possible, vaccines should be administered 2–4 weeks before starting AIIRD treatments that suppress the immune system, but the treatment should never be postponed for a vaccination. Non-live vaccines can be administered to pedAIIRD patients taking glucocorticosteroid or DMARD therapy, but live-attenuated vaccines should be avoided in immunosuppressed pedAIIRD, except for the measles, mumps, and rubella (MMR) booster, and varicella vaccination under specific conditions.

Each recommendation is based on the best current knowledge from studies of scientific evidence or expert opinion. The more stars a recommendation has the stronger the evidence is. However, recommendations with limited scientific evidence may be important, because the experts can have a strong opinion even when the published evidence may be lacking.

One star (*) means it is a recommendation with limited scientific evidence.

Two stars (**) means it is a recommendation with some scientific evidence.

Three stars (***) means it is a recommendation with quite a lot of scientific evidence.

Four stars (****) means it is a recommendation supported with a lot of scientific evidence.


  • Non-live seasonal ‘flu vaccine should be strongly considered for children with pedAIIRD taking steroids or DMARDs.**

The seasonal ‘flu vaccine is not included in national immunization programs, and is usually only for people at risk of having a complicated or serious infection. If your child is taking a glucocorticosteroid or a disease-modifying antirheumatic drug (DMARD) for their pedAIIRD, you should consider taking them for an annual ‘flu vaccine. They can receive a non-live influenza (‘flu) vaccine that will protect them from seasonal ‘flu.

  • Pneumococcal vaccination is recommended in all children with pedAIIRD.**

Pneumococcal infections are common in young children, and include respiratory and ear infections. Vaccination against a subset of pneumococcal types is included in many national immunization programs as a standard childhood vaccination. Either the PCV10 or PCV13 vaccine is recommended for all children with an AIIRD. A PPSV-23 vaccine once every 5 years is not recommended as standard of care but can be considered in immunosuppressed patients or those with systemic lupus erythematosus (SLE). However, PPSV-23 should be avoided in cryopyrin associated periodic syndrome (CAPS) for safety reasons.

  • Tetanus vaccine should be given in line with recommendations for the general population.**

Your child can receive a tetanus vaccine in line with recommendations in your country. If there is a need for tetanus toxoid vaccination, passive immunization is recommended for children who have received a B-cell depleting therapy (e.g. rituximab) in the past 6 months. There is some evidence that the effect of the tetanus vaccine wears off more quickly in pedAIIRD, so boosters should be given when possible.

  • HPV vaccine should be strongly considered in JSLE patients.**

If your child has juvenile systemic lupus erythematosus (JSLE), it is strongly advised that they be vaccinated against human papilloma virus (HPV). The HPV vaccine is included in the national immunization program for young adolescent girls in most countries, and helps to prevent cervical cancer.

  • MMR booster can be given to children on methotrexate;**** it can also be considered in patients treated with some other DMARDs.**

Children taking methotrexate can receive a booster against measles, mumps, and rubella (MMR). It can also be considered in children treated with low-dose glucocorticosteroids, tumour necrosis factor inhibitors (TNFi), or therapies directed against interleukin-1 or -6.

  • VZV vaccination should be strongly considered in patients on MTX who have not had chickenpox;** it can also be considered in patients treated with some other DMARDs.*

Children taking methotrexate can receive a vaccine against varicella zoster virus (VZV) if they have not had a chickenpox infection. VZV can also be considered in children treated with low-dose glucocorticosteroids, TNFi, or therapies directed against interleukin-1 or -6. The risk of having a severe infection is increased if your child has pedAIIRD, so it is preferable to immunize in a controlled manner, rather than waiting for natural exposure to chickenpox.

  • Yellow fever vaccination should be avoided in all immunosuppressed* patients.

If your child is classed as immunosuppressed, they should not receive a yellow fever vaccination. A single dose gives lifetime protection, but there is currently no evidence on the safety of this vaccine in children with a pedAIIRD.


Infectious diseases represent a great burden and risk for immunosuppressed children, yet many parents do not take the recommended vaccinations for their children. Overall, these recommendations give guidance to health professionals and parents about the use of vaccines in children with a pedAIIRD. The recommendations may be used to guide the development of national and local strategies to support best clinical practice.

Recommendations with just one or two stars are based mainly on expert opinion and not backed up by studies, but these may be as important as those with three or four stars. If you have any questions or concerns about your disease or your medication, you should speak to a health professional involved in your care.

Further Reading
If you would like to look at the full recommendations, you can find them here. https://ard.bmj.com/content/74/6/954

Disclaimer: This is a summary of a scientific article written by a medical professional (“the Original Article”).
The Summary is written to assist non medically trained readers to understand general points of the Original Article. It is supplied “as is” without any warranty. You should note that the Original Article (and Summary) may not be fully relevant nor accurate as medical science is constantly changing and errors can occur. It is therefore very important that readers not rely on the content in the Summary and consult their medical professionals for all aspects of their health care and only rely on the Summary if directed to do so by their medical professional. Please view our full Website Terms and Conditions.

Date prepared: January 2023
Summary based on research article published on: 20 June 2022
From:Jansen MHA, Rondaan C, Legger GE, et alEULAR/PRES recommendations for vaccination of paediatric patients with autoimmune inflammatory rheumatic diseases: update 2021Annals of the Rheumatic Diseases 2023;82:35-47

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