43. National survey of administration of live-vaccines to children on methotrexate or biologic therapies for JIA

Abstract

Background: Varicella, measles and flu remain major concerns for public health, clinicians and parents. Non-immunity and the risk of contact cause anxiety, lost schooling, interruption of immunomodulation, expensive intervention and potential morbidity. These risks may be mitigated by vaccination. Non-live vaccines are considered safe in patients on DMARDs/biologic agents, but national guidelines3 recommend withholding live-vaccines. Since Davies and Woo2 survey of confidence to immunize found 13% services gave live vaccines in this population, a body of evidence has built up to question this orthodoxy4 Aims: Test whether recent evidence of safety and efficacy of livevaccine use has been associated with change in practice across the UK; explore the gap between national guidelines and practice and identify whether there is scope to standardise practice. Methods: Survey design, with a questionnaire, supported by the topic specific research group and circulated via BSPAR for doctors and nurses to complete. Results: 38 completed responses from 19 consultants (all paediatric), 17 nurses, 1 junior doctor and 1-pharmacist from >20 hospitals (13/15 tertiary centres; 5 respondents withheld location). 76% refer to a formal local policy, informed by routine guidance (RCPCH6 63%, Green Book3 63%, RCN5 58% and BSR1 42%). 32% have used EULAR evidence-based recommendations4 (2011) which reports the weight of latest research. 12 respondents (32%) from at least 8 tertiary centres have administered live-vaccines concurrently with MTX. No adverse events were identified. Our report of vaccination practice differs significantly from Davies and Woo2 confidence to give live-vaccinations (3 respondents (13%) from 23; p =0.02). Our study showed greater confidence in the use of VZV vaccine over MMR (p =0.015). Two respondents use live flu vaccine Confidence in live-vaccination concurrently with antiTNF's was low (3 respondents from 2 centres). There was one report of use with anakinra. Two respondents would use live-vaccination with low dose (<0.2mg/kg) prednisolone, but none with higher doses. Reported barriers to change include lack of evidence/research (77%), anxiety about safety (58%), local policies (46%), live-vaccines unnecessary (8%), lack of experience (12%). Free text responses demonstrate willingness for change. Conclusions: There remains a wide variation in practice but significantly more respondents now use live-vaccines concurrent with MTX, especially for VZV, compared to 2002. If live-vaccines are used with MTX the need for use with biologics is greatly diminished. Evidence from HIV and oncology experience may help to standardise practice which should be monitored by routine reporting of incidence and safety.