Booster vaccination of children with juvenile rheumatoid arthritis with the Pneumovax 23 vaccine at the cardiorheumatology Department of VDCB VSMU. N. N. Burdenko

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Relevance. Pneumonia is one of the leading causes of child mortality worldwide. In severe infections caused by pneumococcus, more than 95% of cases are caused by pneumonia. Mortality from pneumococcal infection in childhood is typical primarily for developing countries, while in the European region, pneumonia remained the leading cause of mortality in children in the first five years of life [1]. The incidence of JRA ranges from 2 to 16 per 100,000 children under the age of 16 [2]. The development and progression of JRA is determined by a complex combination of genetically determined and acquired defects in normal immunoregulatory mechanisms that limit the pathological activation of the immune system in response to potentially pathogenic stimuli. Patients with rheumatic diseases show various phenotypic and functional defects in the functioning of T-lymphocytes, as well as inhibition of phagocytosis and hypocomplementemia, which leads to a 2-4-fold increased risk of infections in patients with rheumatoid arthritis and other rheumatic diseases compared with the general population. Disease-modifying immunosuppressive antirheumatic drugs, including prednisone, and especially methotrexate, as well as tumor necrosis factor blockers used in recent years, further exacerbate immune defects, which leads to the addition of infections, including opportunistic ones. One of the main causes of death and the development of comorbid infections for patients with rheumatic diseases is pneumococcal infection. The source of a pneumococcal infection is a person in whose body there is a pathogenic bacterium that causes the disease. The first stage of all types of pneumococcal infection is carriage, which also contributes to the spread of antibiotic-resistant strains. Patients with weakened immune systems are more likely to be diagnosed with pneumococcal infection. In addition, pneumonia and sepsis occupy key positions among the causes of death in people with rheumatoid arthritis. Children suffering from JRA are susceptible to infections due to disorders in the immune system that underlie the disease. Also, the use of immunosuppressive drugs in juvenile arthritis can lead to a decrease in immune defenses. Repeated infections can worsen the situation in JRA and in some cases even cause death. This forces the current treatment to be stopped, which has a negative effect on the possibility of achieving or maintaining remission of the disease. In addition, infectious diseases significantly increase the cost of treating patients, since infections in this clinical group can manifest themselves in a more severe form. This leads to the need to use backup antibiotics and intravenous immunoglobulins. Therefore, immunization of such patients plays an important role in the prevention of infectious diseases. In this regard, recommendations on safe vaccination for people with rheumatic diseases have been created in several countries. These recommendations, in particular, are aimed at protecting against infections caused by antibiotic-resistant pneumococci. In recent years, in those countries where the pneumococcal polysaccharide conjugate vaccine is included in the vaccination calendar, it has been possible to significantly reduce the number of cases of pneumococcal infection. A gradual increase in the number of vaccinated people, even if it is not complete, significantly reduces the number of cases of invasive pneumococcal diseases among the population of all ages. It also helps to develop collective immunity and reduce the spread of virulent bacterial carriage. The scale of vaccine prevention of pneumococcal infection is increasing annually, but the proportion of children who have received a completed course of vaccination remains insufficient (64.6% in 2019) [1]. The European Antirheumatic League recommends that all patients with rheumatic diseases receiving immunosuppressive therapy be vaccinated against pneumococcus [3]. Since the end of 2014 (as amended in 2017), vaccination against pneumococcal infection in the Russian Federation has become part of the national calendar of preventive vaccinations for children aged two months to five years, as well as for children at risk and young people who have reached military age.

Goal. To study the results of vaccination against pneumococcal infection in children with JRA for its prevention and improvement of the quality of life of children with arthritis.

Materials and methods. A retrospective analysis of the medical records of patients with JRA who underwent Pneumovax 23 immunization at the Cardiorheumatology department of the VDKB of the N. N. Burdenko State Medical University was carried out. The study included 14 children (7 girls and 7 boys) aged 2-18 years with JRA, vaccinated with Pneumovax 23 vaccine at a dose of 0.5 ml. After vaccination, 6 months later, catamnestic monitoring of changes in indicators and their comparative analysis were carried out 6 months before vaccination and 6 months after vaccination. When taking into account the results, the following indicators were evaluated: leukocytosis, ESR, CRP, the number of ARI episodes before and after vaccination, the frequency of antibiotic prescribing, the frequency of exacerbations of the underlying disease, as well as changes in the disease activity in the diagnosis. The information received was statistically analyzed.

The results of the study. In the group of children with JRA, 8 out of 14 children had a decrease in the number of ARI episodes after Pneumovax 23 vaccination, 2 did not change, and 4 children had an increase. As a result of the analysis of medical records and outpatient records, it was found that in 11 children (79%) the activity level of the underlying disease remained unchanged both before and after vaccination. One child showed a decrease in the activity of the disease, while 2 other children showed an increase in it. In addition, the frequency of prescribing antibiotics after vaccination decreased in 7 children, in 5 children before and after vaccination there was no need to prescribe antibiotics, and in 2 children the frequency of their prescribing increased. These data indicate that the course of ARI after vaccination has become easier and less pronounced compared to the period before vaccination. It can be assumed that the immune response caused by the vaccine is able to stabilize inflammatory processes and strengthen the protective functions of the body. Laboratory parameters after vaccination changed as follows: the number of white blood cells in every second child increased and in the rest decreased. After vaccination, the ESR level decreased in 7 children, in 5 it increased, and in 2 it remained the same as before vaccination. The level of CRP decreased in 10 children after vaccination, and increased in 4 children. A decrease in ESR and CRP in most children may indicate a decrease in inflammatory activity in the body after vaccination. It is important to note that all children successfully survived the post-vaccination period without complications, which underlines the safety of the vaccination. Within six months after the introduction of Pneumovax 23, 12 children had no exacerbations. At the same time, 6 months before vaccination, 9 children also had no exacerbations of JRA, 3 had 3 episodes of exacerbations, and 2 children had 2 exacerbations of the disease. It is important to note that the variety of children's reactions to vaccination may depend on a number of factors, such as the individual characteristics of the immune system, genetic predisposition and the presence of concomitant diseases.

Conclusion. It is possible to reduce the risk of infectious diseases in children with systemic JRA by using such an effective and economically justified measure as vaccination. The study showed that the Pneumovax 23 vaccination against pneumococcus in children with severe form of JRA has a positive effect on reducing the number of episodes of acute respiratory viral infections, reducing leukocytes, ESR, and CRP. The absence of infections in a child suffering from an autoimmune or autoinflammatory disease reduces the risk of exacerbation of the underlying disease, which has a positive effect on improving the quality of life. The administered vaccine did not have a negative effect on the course of the underlying disease, nor did it provoke any side effects after its use.

About the authors

Irina Olegovna Berchian

Voronezh State Medical University named after N. N. Burdenko

Author for correspondence.
Email: ber4ian@yandex.ru
ORCID iD: 0009-0005-2878-063X
Russian Federation, 12 Studencheskaya Street, 394036 Voronezh, Russian Federation

Larisa Vasilevna Moshurova

Voronezh State Medical University named after N. N. Burdenko

Email: pedfacultetvrn@mail.ru
ORCID iD: 0000-0002-5676-4224

Candidate of Medical Sciences, Associate Professor of the Department of Propaedeutics of Childhood Diseases and Polyclinic Pediatrics

Russian Federation, 12 Studencheskaya Street, 394036 Voronezh, Russian Federation

Elena Ivanovna Zhuravleva

Voronezh State Medical University named after N. N. Burdenko

Email: zhyravleva.nayka@mail.ru
ORCID iD: 0009-0001-7681-0945

Assistant of the department of propaedeutics of childhood diseases and polyclinic pediatrics

Russian Federation, 12 Studencheskaya Street, 394036 Voronezh, Russian Federation

References

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