1 - Serviço de Pediatria, Hospital de Vila Franca de Xira, Vila Franca de Xira
2 - Unidade de Reumatologia Pediátrica, Área da Mulher, Criança e Adolescente, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
- 25th European Paediatric Rheumatology Congress, Lisboa, 5 a 8 de setembro de 2018, poster
Resumo:
Introduction: It is being recognized that serologic response to vaccines may be impaired in pediatric patients with rheumatic diseases (pedRD), related to the disease and immunosuppression. In 2017, Portuguese National Vaccination Programme (PNV) postponed tetanus and diphtheria immunization from 20 to 25 years and may pose these patients at even higher risk. At the moment, there are no published data in Portuguese pedRd.
Objectives: Evaluate serologic response to vaccines in Portuguese pedRD receiving immunosuppressive treatment (IT).
Methods: Thirty children with RD attended in a Pediatric Rheumatology Unit, under immunosuppression, were recruited between January to March of 2018. Blood analyses were processed in the same laboratory. Serum samples for Diphtheria-Tetanus (DT) antitoxin antibodies were obtained on the date of recruitment. Laboratory reference values for tetanus and diphtheria antitoxin antibodies (TAA and DAA) recommends: vaccination for values under 0.1 UI/mL (TAA and DAA), and booster for values under 0.5 (TAA) and 1 UI/mL (DAA). Anti-hepatitis A and anti-HBs antibodies were evaluated in different times before and along the treatment. Pos-vaccination anti-varicella-zoster virus (anti-VZV) IgG antibodies were measured during the first three months of IT. All had the PNV for the vaccines (V) analyzed, updated, previously and during IT. HBV and Tetanus-Diphtheria (TD) V were administrated, according the PNV (HBV:3 doses in the first year; TD: 3 doses in the first year, 18 months, 5 and 10 years). HAV and VZV are not included in the PNV. VZV was administrated in susceptible patients before starting IT. All had normal previous immunoglobulins and complement evaluation and no history of frequent or severe infections.
Results: 30 children (13±5 years); 19 female (63%) with diagnosis including juvenile idiopathic arthritis (JIA, n=18), SLE/others connective tissue disease (n=6), vasculitis (n=2), auto-inflammatory diseases (n=1), chronic uveitis (1); with mean disease duration of 42±37 months and total IT of 27±28 months. Almost all (n=27) had history of high IT for longer than 3 months. IT included biologics (anti-TNF) (n=8); Glucocorticoids (GC) (n=7), methotrexate (MTX) (n=19); Cyclosporine (n=2) and Ciclophosphamide (n=1). In the last three months 17/30 have been under high IT (of which 8 with anti-TNF). TAA was evaluated in 28/30, of those 7 (25%) revealed unprotected values (<0.5), in patients with ages ranging from 3 to 16 years (median 11±5 years). Six were on high IT (anti-TNF in 3; MTX+GC in 2; MTX alone in one), and one in “low” MTX dose (a 16-year-old). DAA was obtained in 27/30; with unprotected values (<1UI/mL) in 67%(n=18); of those, three had results under 0.1 UI/mL (16 year old under MTX “high”; 17 year- old with GC and MTX “low”; 8 year-old with MTX “high”). Pre-treatment AcHBs evaluation was negative in 15/30 (mean ages 16+/- 3 years). Booster doses were administrated during IT in 6 of these; of those, 3 persisted negative (all under anti-TNF). HAV was administrated in 21/30 (nine one dose only; twelve two doses). Anti-HA persisted negative in 5/18 evaluated; 2 in the two doses group. VZV was administered in 9 patients, all 5 with subsequent serologic evaluation had protective values.
Conclusion: Even being a small sample, this is for the best of our knowledge, the first evaluation in Portuguese pedRD. These patients demonstrated impaired responses to the V evaluated and alerts to the real necessity of routine investigation of the humoral response and administration of booster V, even in younger ages. Also it does not seem very cautious to postpone Td vaccination from 20 to 25 years in these patients. More and better designed studies are needed.
Palavras Chave: Immunossuppression, Pediatric Rheumatology, Vaccine Responses.