Can a patient with Kawasaki disease receive vaccines?

Vaccination in Kawasaki Disease Patients

Direct Answer

Yes, patients with Kawasaki disease can and should receive vaccines, but the timing depends critically on disease activity, IVIG administration, and vaccine type (live vs. non-live). 1

Timing Considerations Based on Disease Activity

During Active Disease

• BCG vaccination must be withheld during active Kawasaki disease due to documented local inflammation at the BCG vaccination site occurring in 37-50% of patients. 1
• Other vaccinations should preferably be administered during quiescent disease whenever possible, though high disease activity is not an absolute contraindication. 1

After IVIG Administration

Live-attenuated vaccines (MMR, varicella):

• Measles, mumps, rubella (MMR) and varicella vaccines should be deferred for 11 months after high-dose IVIG administration (the standard 2 g/kg dose used in Kawasaki disease). 1, 2, 3
• This recommendation is based on evidence showing lower seroprotection rates and antibody titers in patients vaccinated with MMR within 9 months after IVIG compared to controls. 1
• If clinically feasible, MMR vaccination should be administered prior to IVIG therapy to ensure adequate immune response. 1
• Research suggests that vaccination at 6 months post-IVIG results in poor seroconversion (88% for measles, only 16% for varicella after single dose), but booster vaccination at 12 months achieves adequate protection. 4

Non-live vaccines:

• All routine non-live vaccines (diphtheria, tetanus, pertussis, Haemophilus influenzae type B, hepatitis A and B, pneumococcal, meningococcal, polio, influenza) can be administered according to national vaccination schedules without delay. 1
• These vaccines are safe and immunogenic even in patients on immunosuppressive therapy. 1

Special Vaccine Recommendations

Influenza Vaccination

• Annual inactivated influenza vaccination is strongly recommended for all children on long-term aspirin therapy (which includes most Kawasaki disease patients during the first 6-8 weeks and those with coronary abnormalities on indefinite therapy). 1, 2, 3
• Only inactivated influenza vaccine should be used, never live-attenuated formulations. 1
• Family members should also receive annual influenza vaccination. 1
• This prevents Reye syndrome risk associated with aspirin use during influenza infection. 1

Varicella Considerations

• The varicella vaccine manufacturer recommends avoiding salicylates for 6 weeks after varicella vaccination. 1
• Some physicians substitute another antiplatelet medication for aspirin during this 6-week period to balance the theoretical vaccine risks against the known risks of wild-type varicella in children on long-term salicylate therapy. 1

Patients on Immunosuppressive Therapy

For Refractory Kawasaki Disease Treated with Biologics

• If infliximab or other biologics are used for IVIG-resistant disease, ideally complete live-attenuated vaccinations 2-4 weeks before initiating these therapies. 1
• Research demonstrates that infliximab therapy can be safely administered even in children who received live vaccinations within 3 months (or BCG within 6 months), with no apparent vaccine-associated infections reported. 5
• However, necessary immunosuppressive treatment should never be postponed due to vaccination schedules. 1

For Patients on Corticosteroids

• High-dose corticosteroids (≥2 mg/kg or ≥20 mg/day for ≥2 weeks) are a contraindication to live-attenuated vaccines. 1
• Non-live vaccines remain safe and should follow national schedules. 1

Algorithmic Approach to Vaccination Timing

Step 1: Assess disease phase

• Active/acute disease → Defer BCG only; other non-live vaccines can proceed
• Convalescent phase → Proceed based on IVIG timing

Step 2: Determine time since IVIG

• <11 months post-IVIG → Give only non-live vaccines
• ≥11 months post-IVIG → All vaccines permissible

Step 3: Consider current medications

• On aspirin only → All vaccines safe (use inactivated influenza)
• On high-dose immunosuppression/biologics → Defer live vaccines

Step 4: Prioritize critical vaccines

• Influenza (annual, inactivated) → Mandatory for aspirin users
• Routine childhood non-live vaccines → Follow national schedule without delay
• Live vaccines → Wait appropriate interval or give before IVIG if possible

Common Pitfalls and Caveats

• Do not delay necessary IVIG treatment to accommodate vaccination schedules - the risk of coronary artery complications far outweighs vaccination timing concerns. 1
• Remember that incomplete Kawasaki disease patients (especially infants <1 year) have higher rates of coronary aneurysms if untreated, so IVIG should never be withheld to complete vaccinations. 2
• Avoid ibuprofen in patients taking aspirin for antiplatelet effects as it antagonizes aspirin's platelet inhibition - this is relevant when managing post-vaccination fever. 1, 2
• Large epidemiological studies show no causal association between routine childhood vaccinations and Kawasaki disease development - in fact, vaccination was associated with transiently decreased Kawasaki disease incidence. 6
• Serological testing after vaccination can be considered in high-risk patients (those on rituximab or high-dose corticosteroids) to confirm adequate immune response, with booster doses given if needed. 1